死亡病案的缺陷分析及对策  

Defect Analysis and Countermeasures of Death Medical Records

作　　者：尹璇[1] 刘锦全[1] 丘永明[1] 肖纯[1] 郭建兵[1] 

机构地区：[1]惠州市第三人民医院,惠州市516000

出　　处：《中国病案》2017年第4期21-24,共4页Chinese Medical Record

摘　　要：目的通过死亡病案审查,分析诊疗过程中存在的问题,提出改进对策。方法选取某院2016年3月-2016年11月的死亡病案329份,按照《广东省病历书写规范》和病案评分表进行检查,分析诊疗过程中的医疗质量情况。结果数据显示329份死亡病案,共8883项审查项目,其中存在缺陷801处,总体缺陷率为9.02%,其中涉及医疗核心制度占比最大,为90.64%,为主要问题所在。结论死亡病案从侧面反映出诊疗过程中存在的主要问题,对策上可以从完善制度修订、前移质量监控重心、推进信息建设三方面着手,从根本上改善医疗核心制度的执行情况,从而提高死亡病案质量。Objective Through the problems existing in the course of diagnosis and treatment, and puts forward some countermeasures. Methods Select a hospital from March 2016 to November 2016 the death of 329 medical records, in accordance with the ＂Guangdong province＂ and medical record writing standard score table for examination, analysis of medical quality in the course of diagnosis and treatment. Results Data show that there are 801 defects in a total of 8883 review of the project, the defect rate is 9.02%, the the main problem of medical core system has the largest proportion 90.64%. Conclusions Death records reflect the main problems in the treatment process, countermeasures can improve the system from the revision, quality control center, promoting the three forward information construction to improve the implementation of core medical system fundamentally, so as to improve the quality of death records.

关 键 词：死亡病案 质量监控 医疗质量 病历书写规范 医疗核心制度 

分 类 号：R197.323[医药卫生—卫生事业管理]