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目的为了提高产科医疗质量,防范医疗纠纷,探索提高产科病案质量方法。方法设计《产科住院病历质控核对表》(简称《核对表》),比较核对表使用前后病历质量情况。结果核对表使用后,产科病案的终末质量检查结果显示,核对表使用后组的甲级病案率比使用前组高,两者差异有高度显著性(P<0.01)。结论核对表的使用将科室一级病案质量监控从定量变为定性,临床医师更容易掌握病历质控要点,大大提高了科室一级病案质量监控的成效。核对表有助提高产科病案质量。
Objective To improve the quality of obstetric care, prevent medical disputes and explore ways to improve the quality of obstetric cases. Methods The “Quality Control Checklist of Obstetrics In-patient Medical Record” (referred to as “Checklist”) was designed and compared before and after using the checklist. Results checklist after use, obstetric medical examination of the final quality of the results showed that the use of the checklist after the Class A case than the use of the former group, the difference was highly significant (P <0.01). Conclusion The use of checklist to the department-level medical records quality control from quantitative to qualitative, clinicians more easily grasp the main points of medical records quality control, greatly improving the quality of departmental records monitoring results. Checklists help improve the quality of obstetric cases.