急诊留观病案质量缺陷及对策  

Quality Defects and Countermeasures of Emergency Medical Records under Observation

作　　者：王玉英[1] 钱远宇[2] 孟冰[2] 王涤非[2] 

机构地区：[1]潍坊医学院附属医院,潍坊市261031 [2]解放军总医院,北京市100853

出　　处：《中国病案》2017年第4期42-44,共3页Chinese Medical Record

基　　金：基金项目:军队医院军人患者住院需求的特点及规律研究(CWS12J125)

摘　　要：目的研究某院急诊留观病案质量存在的缺陷,制定科学的管理对策,以提升急诊留观病案质量及管理水平,切实加强医疗安全。方法随机抽检某院2014年1月-2016年1月的急诊留观病案300份,查找缺陷,分析问题成因,提出对策。结果急诊留观病案质量缺陷主要有14项,其中病史书写欠准确占到39.3%、主诉书写不规范占25.0%、查体不全面占24.3%、重点不明确23.0%等。结论急诊留观病案质量急需提高,应针对产生缺陷的原因,制定全面地控制措施,才能有效提高急诊留观病案质量,将医疗纠纷防患于未然。Objective To study the defects and loopholes of emergency medical records which under observation,and formulate scientific management countermeasures, in order to improve quality and management level of medical records, as well as to strengthen the medical safety. Methods Check randomly 300 medical records of one hospital from January 2014 to January 2016, and find out the defects, analyze the causes, find the problems and put forward the countermeasures. Results The emergency medical records＇ quality defects that under observation mainly contain 14 kinds, including the the writing of history inaccurate account for 39.3%, the writing of chief complaint irregular account for 25%, the physical examination incomplete account for 24.3%, and the key point unclear account for 23%, etc. Conclusions It very urgent to improve the quality of emergency under observation in medical record, and to develop a comprehensive control measures for the cause of defects, in order to improve the emergency under observation in medical record quality, and prevent the medical disputes.

关 键 词：急诊留观 病案质量 缺陷 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]