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目的探讨出院电子打印病案的质量缺陷产生的原因,促进病案管理质量的提高。方法随机抽查2009年7月至2010年7月我院打印出院病案4 800份,依据卫生部颁布的《病案书写基本规范》、《电子病历基本规范(试行)》以及《广东省病历书写规范》进行质量评定。结果发现病案首页、术前讨论、手术记录、病程记录、医学影像检查报告、实验室检查结果等出现缺陷,缺漏情况最普遍。结论加强医师法制观念教育,提高病案记录人员的专业水平,制定严格管理制度,加强各环节管理,是确保病案质量的关键。
Objective To explore the reasons for the quality defect of discharged electronic print medical records and to promote the quality of medical record management. Methods A random sample of 4 800 cases were printed out from July 2009 to July 2010 in our hospital. According to Basic Standards for Medical Records Writing, Basic Rules for Electronic Medical Records (Trial) and Guidelines for Medical Records Writing in Guangdong Province issued by the Ministry of Health, Quality assessment. The results found that the first page of medical records, preoperative discussions, surgical records, disease records, medical imaging test reports, laboratory test results appear defects, the most common gaps. Conclusion It is the key to ensure the quality of the medical record to strengthen the education of physicians on the concept of legal system, improve the professional level of medical record-keeping staff, establish a strict management system and strengthen the management of all aspects.