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目的通过住院病案的缺陷分析,制定对策,提高病案质量。方法以病案书写规范为标准,针对2706份缺陷病案进行分析,总结缺陷原因。结果 2706份缺陷病案存在6大方面31项缺陷。结论应从加强医师的教育培训、认真执行三级医师责任制和加强监管三方面入手提高病案质量。
Objective Through the analysis of the defects of inpatient medical records, make countermeasures to improve the quality of medical records. Methods Based on the norms of medical record writing, 2706 cases of defects were analyzed and the causes of defects were summarized. Results There were 31 defects in 6 major aspects in 2,706 defective cases. Conclusion The quality of medical records should be improved from three aspects: strengthening physician education and training, earnestly implementing the responsibility system of three-level physicians and strengthening supervision.