摘要
目的通过对出院病案终末质量监控,提高病案书写质量。方法根据卫生部、江西省有关病历基本书写规定,对2288份出院病案进行质量检查。结果2288份病案中有335份病案存在书写缺陷,缺陷率为14.6%,共出现缺陷次数1328次。结论加强医护人员的法律意识和责任心,强化病历书写规范,保持病历书写完整。
Objective To improve the quality of medical records writing by the final quality control. Objective Quality of 2288 medical records was checked, based on the basic writing rules issued by Ministry of Health and Jiangxi Province. Results 1328 defects were found in 335 medical records, accounting for 14.6% of the total records. Conclusion It is necessary to enhance health professionals＇ consciousness and responsibility towards law,strengthen the writing rule on medical records and keep the integrity of medical records.
出处
《中国病案》
2010年第1期19-20,共2页
Chinese Medical Record
关键词
病案缺陷
分析
对策
defect
medical records
analysis
strategy
