摘要
目的作为重要的病理资料,病理检查申请和诊断报告单是各级医疗单位医疗质量规范化管理检查的一项重要内容。文章通过回顾性检查病理检查申请和诊断报告单的存在问题及影响因素,提出防范措施,为改进病理科质量控制工作提供科学依据。方法将南京军区南京总医院病理科2012年1-12月共33 696份病理检查申请和诊断报告单逐一进行检查,总结存在问题并分析其原因。结果 33 696份病理检查申请和诊断报告单中,门诊病例19 154份、住院病例14542份。病理检查申请单不合格1760份(5.22%),其中无临床诊断、无病史及无申请医师为主要问题;诊断报告单不合格157份(0.46%),其主要存在问题为标本大体和镜下描写过于简单。结论在病理检查申请和诊断报告单存在问题中,无临床诊断现象较突出。因此应重视相关科室协同合作,从而提高病理检查申请和诊断报告单的质量。
Objective Pathologic examination applications and diagnostic reports are important documents for medical quali- ty examination. This study intended to examine pathologic examination applications and diagnostic reports and analyze the potential problems and influencing factors, so as to provide some evidence for improving quality control in the pathology department. Methods We retrospectively examined 33 696 pathologic examination applications and diagnostic reports in the Department of Pathology of Nan- jing General Hospital in 2012. We summarized the problems in quality control and analyzed their causes. Results Of the 33 696 pathologic applications and reports （19154 for outpatients and 14542 for inpatients）, 1760 applications （5.22%） were not qualified, mostly for absence of clinical diagnosis, medical history, and the name of the application doctor; 157 diagnostic reports （0. ,$6% ） were not qualified, chiefly for insufficient description of gross samples and microscopic findings. Conclusion Absence of clinical diagno- sis is prominent among all the problems with pathologic applications and diagnostic reports, which may be attributed to both the patho- logic and clinical departments. The quality of pathologic examination applications and diagnostic reports can be improved by concerted efforts of relevant departments.
出处
《医学研究生学报》
CAS
北大核心
2013年第8期841-843,共3页
Journal of Medical Postgraduates
基金
南京军区医药卫生科研基金资助项目(2012-04-68)
关键词
病理检查申请
诊断报告单
临床诊断
医疗质量
Pathologic examination application
Pathologic diagnostic report
Clinical diagnosis
Medical quality
