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目的提高死亡病案书写质量。方法采取回顾性死亡病案书写质量调查法。对我院2008年8月到2009年6月出院的死亡病案检查中发现的缺陷原因进行分析。结果死亡病案质量存在的主要问题是部分医师对病历书写规范新知识更新不快,上级医师指导把关不够,部分医师对病历书写重要性缺乏足够重视。结论组织临床医师学习病历书写规范细则,制定死亡病案质量检查标准,加强死亡病案质控力度,建立奖惩制度等多方面措施相结合的方法 ,从而使死亡病历书写质量明显提高。
Objective To improve the quality of death record writing. Methods Retrospective death disease record writing quality survey method. Analysis of the causes of the defects found in the death check-ups discharged from our hospital from August 2008 to June 2009. Results The main problem of the quality of death medical records is that some physicians are not satisfied with the updating of medical records specification norms, lack of guidance from superior doctors and insufficient attention of some doctors on the importance of medical records writing. Conclusion The organization of clinicians to learn medical records writing rules and regulations, the development of death medical records quality inspection standards, strengthen the quality control of death cases, the establishment of rewards and punishments and other measures to combine methods, so that the quality of death medical records significantly improved.