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目的了解某医联体医院诊断证明书的书写质量状况,提高书写质量,改善患者就医体验。方法本研究根据某院门诊部2016年7月-2016年12月质控检查记录,对27个科室2124份诊断证明检查记录结果进行分析。结果 27个科室中产科、妇科、骨科、眼科和急诊科开具诊断证明书超出100份,2124份诊断证明书中有493份不合格,不合格率为23.21%,妇科不合格率最低为4.00%。不合格原因以患者职别及住院/门诊编号未书写占比最多,分别为44.62%和34.08%,其中有436份患者断证明书一次性盖章不成功,以未书写就诊日期及医师未亲笔签名占比最多,患者不满意有25份,其中引起争执的19份,投诉6份。结论根据分析结果采取改进诊断证明书格式,提供正确的诊断证明书填写标准模板,加强诊断证明书书写规范化培训,质量情况纳入质量考核指标中等措施,规范诊断证明书的书写,保证书写准确无误,提高患者诊断证明书盖章成功率,改善患者就医体验。
Objective To understand the writing quality of medical certificate in a medical hospital, improve the writing quality and improve the medical experience of patients. Methods According to the records of quality control inspection from July 2016 to December 2016 in a hospital outpatient department, this study analyzed the results of 2124 diagnosis and test records in 27 departments. Results The diagnosis certificates of obstetrics, gynecology, orthopedics, ophthalmology and emergency department in 27 departments exceeded 100, 493 out of 2124 diagnostic certificates were unqualified, the unqualified rate was 23.21%, the lowest gynecological unqualified rate was 4.00% . The reasons for unqualified patients and hospital / outpatient numbers did not write the largest proportion, respectively, 44.62% and 34.08%, of which 436 patients with a one-time seal stamped unsuccessful, did not write the date of treatment and the doctor did not personally Signatures accounted for the largest number of patients were dissatisfied with 25, of which 19 were controversial, 6 complaints. Conclusion According to the results of the analysis, it is necessary to improve the format of diagnosis certificate, provide the correct diagnosis certificate, fill in the standard template, strengthen the standardized training of writing the diagnosis certificate, and take the quality conditions into the intermediate measures of quality assessment, standardize the writing of the diagnosis certificate, ensure accurate writing, Improve the success rate of the patient’s diagnosis certificate stamped and improve the patient’s medical experience.