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目的查找病案质量缺陷及产生原因,以寻找改进或提高病案书写质量的策略。方法对4375份住院病案按北京市卫生局《住院病案(终末)书写质量检查表》进行检查及统计分析。结果 4375份出院病案均有缺陷,其中未填写和未记录占39.3%,填写或书写不规范不完整占32.7%,概念或书写错误占28%。结论医师责任心不强、基础知识不扎实及医师结构不合理是导致病案质量不高的主要原因。因此,通过专业培训,强化医师的基本功训练和责任心,加强三级医师责任制,注重病案环节质量的监控,是一项长抓不懈的系统工作,需要全体医务人员共同努力。
Objective To find out the defects of the medical records and their causes, in order to find a strategy to improve or improve the quality of medical records. Methods 4375 inpatient medical records were checked and statistically analyzed according to the Inpatient Medical Record (Final) Writing Quality Checklist of Beijing Municipal Health Bureau. Results All the 4,375 discharged cases were flawed. Among them, 39.3% were unaccounted and did not record, 32.7% were incomplete or incomplete, and 28% were conceptual or written errors. Conclusion Physicians’ low sense of responsibility, lack of solid basic knowledge and irrational physician structure are the main reasons for the poor quality of medical records. Therefore, through professional training, strengthening the basic training and sense of responsibility of the physicians, strengthening the responsibility system of the three-level physicians and monitoring the quality of medical record links is a long-term and unremitting systematic work that requires the joint efforts of all medical staffs.