论文部分内容阅读
目的了解死亡病案质量问题。方法对240份死亡病案质量进行回顾性调查分析。结果 240份死亡病案中出现质量缺陷为:抢救或死亡记录内容有缺陷占52.08%,死亡讨论过于简单占12.92%,死亡时间不一致占8.75%,无最后诊断占10.42%,重要检查结果无记录或无分析占13.33%,应有而无患者授权委托书或签名者非被委托人占10.42%。结论加强对死亡病历的书写,重视是根本,措施是关键,落实、监督是保证。所有的医务人员应该认真按规范书写各种医疗文件。
Objective To understand the quality of death medical records. Methods Retrospective analysis of 240 cases of death medical records. Results The quality defects in 240 death cases were as follows: 52.08% of the records of rescue or death, 12.92% of the deaths were discussed in simple terms, 8.75% of the inconsistent deaths, 10.42% of the patients did not have the final diagnosis, No analysis accounted for 13.33%, there should be no patient power of attorney or signatory non-client accounted for 10.42%. Conclusion To strengthen the writing of death records, attention is the fundamental measure is the key to implement, supervision is a guarantee. All medical staff should carefully write all kinds of medical documents according to the regulations.