论文部分内容阅读
目的:探讨妇产科病历书写存在的一些常见问题,并提出提高病历书写质量的对策。方法:随机选取2012年5月~2013年3月在浙江省江山市妇幼保健院存档的妇产科病历共200份,由经验丰富的护理人员进行检查,病历内容包括妇产科体温单、医嘱执行、产前记录、产程图、产时记录、产后护理记录单等。结果:通过对这200分妇产科病历书写存在的一些问题进行分析,发现存在着体温单记录有误,医嘱执行不到位,产前记录有误,产程图记录不详细或混淆,产时记录出错,产后护理记录单出错等问题。结论:根据结果显示,妇产科病历书写仍旧存在比较多的问题,可见书写人员对于《病历书写规范》的了解程度不足,因此医院的相关质量检测人员应将重点目标转移在该点上,使病历书写更加规范。
Objective: To discuss some common problems in the writing of medical records of obstetrics and gynecology and to put forward some countermeasures to improve the writing quality of medical records. Methods: A total of 200 cases of obstetrics and gynecology were archived from May 2012 to March 2013 in Jiangshan Maternal and Child Health Hospital of Zhejiang Province, and were inspected by experienced nurses. The medical records include body temperature list of obstetrics and gynecology, doctor’s orders Implementation, prenatal records, labor plans, maternity records, postnatal care records and so on. Results: According to the analysis of some problems existed in obstetrics and gynecology records of these 200 points, we found that there were errors in single temperature record, improper execution of medical orders, incorrect prenatal records, unspecified or confused labor records, Mistakes, mistakes in postnatal care records and other issues. Conclusions: According to the results, there are still many problems in the writing of medical records of obstetrics and gynecology. It is obvious that writers’ lack of understanding of “medical records writing norms” means that relevant quality inspectors in hospitals should transfer their key objectives to this point. Medical record writing more standardized.