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目的了解诊断书写质量,有针对性的制定解决对策。方法对689份病案质量检查缺陷中的诊断问题进行回顾性调查分析。结果不规范的诊断问题占检查病案所有问题的14%,有35%的病案存在诊断书写缺陷。结论存在的诊断质量问题重点在书写质量方面。改进主要在于提高医师重视程度,加强上级医师检查和指导,为医师提供规范诊断词库和细化关于诊断书写的要求等。
Objective To understand the quality of diagnostic writing and to formulate solutions to the problem. Methods A retrospective investigation was made on the diagnosis of 689 defects in medical records. The results of non-standard diagnostic problems accounted for 14% of all problems in the examination of medical records, 35% of medical records exist defects in the diagnosis. Conclusions The quality of diagnosis that exists is focused on the quality of writing. Improvement mainly lies in improving the degree of doctor’s attention, strengthening the inspection and guidance of the higher physicians, providing doctors with standardized diagnostic thesaurus and refining the requirements of the diagnostic writing.