浙江省病历书写质量现状与对策  

Present Situation and Countermeasures of Medical Records Writing in Zhejiang Province

作　　者：徐莉[1] 潘胜东[1] 夏萍[1] 李伟 梁廷波[1] Xu Li;Pan Shengdong;Xia Pin;Li Wei;Liang Tingbo(The Second Affiliated hospital of Zhejiang.University School of Medicine, Hangzhou 310009, Zhejiang Province, China)

机构地区：[1]浙江大学医学院附属第二医院,杭州市310009 [2]浙江大学医院管理办公室,杭州市310029

出　　处：《中国病案》2018年第4期6-10,共5页Chinese Medical Record

摘　　要：目的通过分析浙江省61家三级甲等医院病案质量抽查结果,发现目前病历书写中存在的主要问题,为今后病历质量持续改进提出对策建议。方法抽查浙江省61家三级甲等医院每家医院10份住院病案共610份,对病案的基础质量和内涵质量问题运用SPSS17.0软件进行统计分析。结果在病案基础质量部分8个维度33项指标中,扣分条目数位于前三的维度分别是病历记录不合理复制、医疗文书缺失与基础错误,缺陷率依次为54.22%、7.42%与5.44%;33项指标缺陷率顺位前五的分别是首次病程记录与入院记录相互复制、日常病程记录内容千篇一律、病历记录机械导入检查检验结果无分析意见、围手术期资料缺失、授权委托书缺失或无效;在病案内涵质量部分中,对诊断有重要意义的化验、特殊检查、病理检查等结果未记录缺陷率为30.37%,诊疗知情同意与病情谈话内容不规范缺陷率占26.64%,首次病程录中对诊断不明的未书写鉴别诊断缺陷率占17.94%,此三项为缺陷率最高的指标。结论病历书写质量在完整的医疗体系中有着重要作用和意义,做好病历书写质量的持续改进应从提高认识、强化书写责任意识、建立完善的质量监控反馈体系以及奖罚分明的制度体系等方面着手。Objective In this paper, the results of the medical records of 61 grade A hospitals in Zhejiang province were analyzed, finding out the main problem in current medical record writing, to propose countermeasures for improving the quality of medical records in the future. Methods 610 medical records of 61 grade A hospitals in Zhejiang province were selected, and SPSS17.0 software was used for statistical analysis of the basic quality and quality of the medical records. Results Among the 33 indicators in 8 dimensions of the basic medical records, The first three dimensions of deductions are the unreasonable medical records, the missing medical documents and the basic errors, with the defect rates of 54.22%, 7.42% and 5.44%,respectively, The top five indicators of the 33 indicators of the defect rate are the first course of the record and admission records were copied to each other, routine medical records were identical, no analysis was made on the results of mechanical import inspection, perioperative information was absent, the power of attorney is missing or invalid; in the part of the quality of the medical record, the defect rate was 30.37% for the diagnostic tests, special examinations and pathological examinations,the defect rate accounted for 26.64 percent of the ＂undisciplined and informed consent for diagnosis and treatment＂, the defect rate of unwritten differential diagnosis of unknown diagnosis in the first course was 17.94%. Conclusions The quality of writing medical records plays an important role in the whole medical system, continuing to improve the quality of medical record writing should start with raising awareness, strengthening the awareness of writing responsibility,establishing a sound feedback system for quality control, and a system of rewards and punishments.

关 键 词：病历书写 质量 现状 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]