214份死亡病案首次病程记录书写质量分析  

Quality Analysisof the First Course Records of 214 Death Medical Records

作　　者：陶晓钦 程小维 李莹 邓明德 Tao Xiaoqin Cheng Xiaowei Li Ying Deng Mingde(Quahty Control Department of The Second Affihated Hospital of The Third Military Medical University, Chongqing400037, China)

机构地区：[1]第三军医大学第二附属医院质量控制管理科,重庆市400037

出　　处：《中国病案》2016年第12期13-15,共3页Chinese Medical Record

摘　　要：目的通过分析死亡病案首次病程记录书写存在的缺陷,寻求改进措施,进一步提高死亡病案内涵质量,保障医疗安全。方法采用回顾性死亡病案书写质量分析法。按照《军队医院病历书写与管理规则》《病历书写基本规范》及某院《死亡病案质量检查表》的相关要求,对某院2015年1月至12月214份死亡病案中的首次病程记录书写存在的问题进行分析,使用描述性统计方法。结果 214份死亡病案首次病程记录主要存在的问题是病例特点未认真归纳提炼占36.15%,缺鉴别诊断或讨论不充分占23.85%,诊疗计划不具体,无针对性占16.15%。结论加强医务人员培训,夯实"三基"知识,充分发挥科级质控作用,提高主治医师教学查房质量,坚持会议通报与病案展评制度等措施,对提升死亡病案内涵质量有重要意义。Objective Through the analysis of death the flaws of the medical record writing course record for the first time, to fmd measures to further improve the quality ofconnotation, and ensure medical safety. Methods Using the method of retrospective medical record writing quality of death. According to the requirements of the army hospital medical record writing and management rules, medical record writing basic specifications anddeath medical record quality inspection table, analyze existing problems inthe First Course Records of 214 deathmedicalrecords and use descriptive statistics method. Results The main problems existing in 214 death course record for the first time were not carefully refined （36. 15%）, lack of differential diagnosis or inadequate discussion （23.85%）, diagnosis and treatment plan is not specific, no specific accounted for 16. 15%. Conclusion Strengthen medical personnel training, strengthen ＂three basis＂ knowledge, give full play to the levelquality control, improve the quality of attending physician teaching rounds, insist on meeting report and medical records selection system and other measures, enhance the connotation of death medical record quality have great significance.

关 键 词：死亡病案 首次病程记录 质量分析 

分 类 号：R197.323[医药卫生—卫生事业管理]