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目的对住院病案的出院记录部分存在的问题进行分析,提出相应对策以提高病案质量。方法依据国家卫生部颁发的《病历书写基本规范(试行)》的有关规定,结合我院病历书写要求对613份归档病案进行出院记录质量的专项检查,检查包括出院记录中的一般情况、入院情况、入院诊断、诊疗经过、出院情况、出院后注意事项以及医师签名等共12项内容。结果问题较多的是出院时无专科检查的占73.90%,出院诊断与病案首页、入院记录中的最后诊断不一致的现象占33.44%。结论通过出院记录专项检查,更加体现出病案质量检查从形式检查重心向诊疗行为干预检查转移的重要性,从而进一步提升病案质量控制的内涵。
Objective To analyze the existing problems in the discharge records of inpatient medical records and put forward corresponding countermeasures to improve the quality of medical records. Methods According to the relevant provisions of the Basic Medical Record Writing Practice (Trial) issued by the Ministry of Health of the People’s Republic of China, we conducted a special inspection on the quality of discharge records of 613 filing medical records in combination with the medical records writing requirements of our hospital. The inspection included the general situation in discharge records, , Admission diagnosis, diagnosis and treatment, discharge, discharge matters and physicians signed a total of 12 items. Results of the more problems are discharged without 73.90% of the specialist examination, discharge diagnosis and the first page of the medical records, admission records in the final diagnosis of inconsistencies accounted for 33.44%. Conclusions The special examination of discharge records can further reflect the importance of the examination of quality of medical records from the center of examination of forms to the examination of medical interventions so as to further enhance the connotation of medical records quality control.