214份死亡病案末次抢救记录质量分析  

Quality Analysis of 214 Death Rescue Records of the Last Time

作　　者：胡水芳 李莹 匡永利 邓明德 

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》2017年第4期14-16,共3页Chinese Medical Record

摘　　要：目的探讨死亡病案中末次抢救记录存在的缺陷,采取有效措施提高死亡病案末次抢救记录的书写质量,确保医疗安全。方法采用回顾性分析法,按照某院《死亡病案质量检查表》《军队医院病历书写与管理规则》《病历书写基本规范》等规范,对2015年全院的214份死亡病案的末次抢救记录进行检查分析。结果 214份末次抢救记录中存在缺陷175条,平均每份病案存在缺陷0.82条,主要存在的缺陷是抢救记录描述不详细占28.00%;家属意见记录不详细占25.14%;上级医师未审签或审签不及时占20.57%,用药剂量、途径等记录太笼统占12.00%。结论从基础、环节、终末质量三个方面,重点规范死亡病案抢救记录的书写,保证抢救记录的及时性、真实性、可靠性、完整性,确保抢救记录在医疗纠纷中发挥有效的举证作用。Objective To investigate the exist defects in death rescue records of the last time, take effective measures to improve the writing quality, and ensure medical safety. Methods Using the method of retrospective analysis, according to a hospital ＂death medical record quality inspection table＂ and ＂the military hospital medical record writing and management rules＂ and ＂the medical record writing basic norms＂, to examine and analyze 214 death rescue records of the last time of 2015. Results There are some defects in the 175 rescue records, average each medical defects 0.82, the main defects is without detailed description accounted for 28.00%; The opinions of family members record without detailed description accounted for 25.14%; Superior doctors not review the signature or review the signature not timely accounted for 20.57%, dosage, ways record too general accounted for 12.00%. Conclusion We should make the specification to ensure the rescue records timeliness, authenticity, reliability, integrity, ensure the rescue records play effective role of proof in medical disputes, from the three aspects of foundation, link and terminal quality.

关 键 词：死亡病案 抢救记录 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]