心血管介入治疗死亡病历缺陷分析及对策  

Analysis and Countermeasures of medical records of cardiovascular interventional therapy

作　　者：谢敏[1] 唐建中[1] 

机构地区：[1]昆明理工大学附属医院云南省第一人民医院,云南昆明650032

出　　处：《基层医学论坛》2017年第19期2466-2468,共3页The Medical Forum

摘　　要：目的分析某综合性三甲医院3年中心血管介入治疗死亡病历书写缺陷,为医院重点部门、关键环节的监管和专科建设提供数据。方法从病案查询系统收集2013年—2015年介入治疗死亡病历的信息,统计病案首页填写、入院记录、首次病程记录、知情同意书的签署、抢救记录、死亡记录、死亡讨论记录等的缺陷。结果 3年中心血管介入治疗死亡病历缺陷率平稳下降。结论心血管介入治疗死亡病历数据可反映医院急救诊疗、医疗质量等多方面的信息,应加强对此类病历的长期关注和缺陷分析,提高其书写质量。Objective This paper provides the data for the key departments of the hospital.The supervision of key links and the construction of the specialty,which through the defects of the death records of 3 years of central vascular interventional treatment in a comprehensive hospital.Method Query system of 2013-2015 collection of interventional treatment of death medical records information from medical records,medical records,fill out the statistics for the first time admission records,course records,informed consent signed,rescue records,death records and death records to discuss the defects.Results 3 years of central vascular interventional treatment mortality rate decreased steadily.Conclusion The data of death cases of cardiovascular interventional treatment reflect the information of hospital emergency treatment,medical quality and so on.We should pay attention to the long-term concern and defect analysis of this kind of medical record,and improve the quality of death medical record writing.

关 键 词：心血管介入治疗 死亡病历 书写缺陷 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]