风湿免疫科住院医师规范化培训中病历书写缺陷分析  

Defect Analysis of Admission Records in the Resident Training of Department of Rheumatology

作　　者：孔芳[1] 陈丽芬[1] 李霞[1] 苏丽[1] 廖秋菊[1] 赵义[1] Kong Fang;Chen Lifen;Li Xia;Su Li;Liao Qiuju;Zhao Yi(Department of Rheumatology and Allergy,Xuanwu Hospital,Capital Medical University,Beijing 100053,China;不详)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2021年第8期12-15,共4页Chinese Medical Record

摘　　要：目的总结和分析风湿免疫科的规范化培训医师病历书写中的缺陷,为提高病历书写水平提供对策依据。方法随机抽取120份某院风湿免疫科2019年1月~12月的入院记录,进行缺陷总结和原因分析。结果现病史书写缺陷率最高(59.2%),其中阴性症状缺乏最常见,其次是诊疗过程记录不完整和症状记录或采集错误;主诉缺陷第二多见(54.2%),其中主要症状不准确最常见,其次是主诉不简练;体格检查部分缺陷也较为多见(36.7%),最常见的是症状体征混淆以及体格检查和专科查体前后不一致。对所有缺陷进行原因分析,发现52.3%的缺陷是因为专科知识缺乏,25.1%是因为基本功不扎实,17.7%是因为工作态度不认真,还有4.9%的缺陷是对于病案书写规范不了解造成。结论风湿免疫科规培医师书写的入院记录,缺陷率高达50%以上,病案缺陷最主要的原因是专科知识缺乏,其次是基本功不扎实,需针对发生缺陷的原因提出对策,提高规培医师病历书写水平。Objective To investigate the common defects and its cause existing in the admission records in internal medicine residents training in the Department of Rheumatology.Methods A total of 120 medical records of inpatients in the Department of Rheumatology from January to December 2019 were randomly selected for summary and analysis.Results We found that the top 3 defects were in the present history(59.2%),chief complaint(54.2%)and the physical examination(36.7%).In the records of present history,the lack of negative symptoms was the most common problem,followed by incomplete records of diagnosis and treatment process and unclear description of main complaints.The defects of chief complaint were inaccurate symptoms and too many characters.In the records of physical examinations,some residents couldn’t distinguish symptoms from physical signs and the positive physical signs of same patients were inconsistent.Based on the analysis of the causes of all the defects,it was found that 52.3%of the defects were due to lack of specialist knowledge,25.1%due to lack of basic skills,17.7%due to lack of serious work attitude,and 4.9%due to lack of understanding of medical record writing standards.Conclusion The defect percentage of admission records in Department of Rheumatology is more than 50%.The most common cause of these defects is lack of specialized knowledge.Some interventions should be considered to improve the quality of medical records.

关 键 词：入院记录 缺陷 原因分析 

分 类 号：R197.323[医药卫生—卫生事业管理]