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目的应用新的住院病历质量评价标准,以促进病历质量的提高,并分析新标准的应用效果。方法 2012年3月-2013年2月,应用《住院病历质量评价用表》对终末病历进行检查。结果 4796份终末病历甲级率91.14%,单项否决率6.82%,单项否决主要原因是“病历中记录内容互相矛盾”及“会诊未在发出申请后48小时内完成”。结论新的评价标准在提高病历质量、防范医疗风险等方面起到了积极作用,同时也需在应用中不断完善。
Objective To apply the new quality evaluation criteria of inpatient medical record to improve the quality of medical record and to analyze the application effect of new standard. Methods From March 2012 to February 2013, the final medical records were examined using the “Table of Quality of In-patient Medical Records”. Results The 4796 final grade A cases were 91.14% with a single negative vote of 6.82%. The main reason for the single negative decision was that “records contradict each other” and “the consultation failed to be completed within 48 hours after the application was issued.” Conclusion The new evaluation standard has played an active role in improving the quality of medical records and preventing medical risks, etc., and meanwhile it needs to be continuously improved in application.