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目的通过对出院病案存在的缺陷进行分析,查找原因,提出改进措施,达到持续提高目的,减少医疗纠纷,确保医院声誉及患者安全。方法按出院病案15%以上的比例,对医院2016年度各科室出院病案进行随机抽查,对照江苏省及医院制定的检查评分标准进行打分,采用卡方检验、logistic回归分析统计方法,分析检查结果。结果 2016年抽查出院病案5250份,合格病案4768份,不合格病案482份,病案合格率为90.8%,有转科情况出现不合格病案是无转科者的7.729倍(P=0.001),医师工作量大出现不合格病案是医师工作量正常者的3.334倍(P=0.002),而病案住院时间<10天出现不合格病案仅是病案住院时间>21天者的0.021倍(P<0.001)。结论有转科情况、医师工作量大和住院时间长对病案质量影响较大。对此,应加强病案书写规范培训,重点关注有转科、长时间住院和工作量大科室的病案书写,加强各级医务工作者的质量意识,从而持续提高病案书写质量。
OBJECTIVE To analyze the causes of the discharged medical records and find out the reasons and put forward the improvement measures to achieve the purpose of continuous improvement, reduce the medical disputes and ensure the hospital reputation and patient safety. Methods According to the rate of more than 15% of the discharged medical records, we randomly selected the hospital discharge cases in 2016 and compared them with the test scores established by Jiangsu Province and the hospitals. The results were analyzed by chi-square test and logistic regression analysis. Results In 2016, 5,250 medical records were found, 4768 were eligible, 482 were unqualified, and 90.8% were unqualified. There were 7.729 times as many unqualified cases as those without (P = 0.001) The number of unqualified medical records was 3.334 times of the normal workload of physicians (P = 0.002), while the number of unqualified medical records of less than 10 days was 0.021 times of those of medical records of 21 days (P <0.001) . The conclusion is that there is a change in the status of the medical records, the physician workload and length of hospitalization have a greater impact on the quality of medical records. In this regard, medical records should be standardized norms to strengthen training, with a focus on transfer subjects, prolonged hospitalization and workload of department record writing, strengthen the quality awareness of medical workers at all levels, so as to continuously improve the quality of medical records writing.