6612例出院记录缺陷分析  

Defects Analysis on 6612 Cases of Discharge Records

作　　者：毛甜甜[1] 伍姗姗[1] 吴玮斌[1] 杨旭丽[1] 黄祖凤[1] 廖君 谭昊曲 

机构地区：[1]南昌大学第一附属医院质控科,南昌市330006

出　　处：《中国病案》2018年第1期15-18,共4页Chinese Medical Record

基　　金：江西省卫生厅普通科技计划课题(20141051)

摘　　要：目的通过对某三甲医院出院记录进行质量分析,了解该院出院记录书写存在问题。方法自2014年1月-2016年12月每月每病区随机抽查3份归档病案,共6612份,对病案中出院记录按照入院时情况、诊疗经过、出院时情况、出院诊断、出院医嘱、医师签名等项目进行检查并统计分析。结果 1370份出院记录存在缺陷,缺陷率为20.72%。主要是诊疗经过不具体、出院医嘱不详细、入院时情况不完整、出院时情况太简单、缺医师签名、出院诊断与病情不符或漏写。缺陷率前5名科室分别为肿瘤科47.87%、耳鼻喉科35.48%、骨科29.01%、心胸外科27.57%、泌尿外科27.46%。结论对医师加强病历书写规范培训,落实三级医师责任制度,完善奖惩机制,优化病历系统,加强医师对病历书写的重视,努力提高病案质量。Objectives By analyzing the writing quality of the discharge records of a Three A and Tertiary Hospital, to know the problems existing in the writing of the hospital discharge records. Methods From January 2014to December 2016, 3 archived medical records were randomly selected every month in the ward, a total of 6612 copies, The discharge records in the medical records were checked and analyzed statistically according to the condition of admission, the course of diagnosis and treatment, the condition of discharge, the diagnosis of discharge, the doctor＇s orders for discharge and the signature of doctors. Results There were 1370 hospital discharge records existing defects, with a defect rate of 20.72%. The main defects included that the diagnosis and treatment was not specific, the doctor＇s instructions were not detailed, the condition of admission was incomplete, the situation was too simple to leave the hospital, the doctor＇s signature was not required and the discharge diagnosis was inconsistent with the condition or omission. The： top 5 defect rates were oncology 47.87%, Department of ENT 35.48%, Department of orthopedics 29.01%, cardiothoracic surgery 27.57%, Department of Urology 27.46%. Conclusions We should strengthen the training of standardized medical record writing, implement the three grade doctor responsibility system, perfect the reward and punishment mechanism, make doctors pay more attention to medical records writing, and improve the quality of medical records.

关 键 词：病案 出院记录 缺陷分析 

分 类 号：R197.323[医药卫生—卫生事业管理]