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目的探讨某院院前急救病案存在的问题,分析改进措施前后病案质量有无差异。方法 2013年1月采用针对性的改进措施,比较改进措施前(2012年2-7月)和改进措施后(2013年2-7月)院前急救病历的病历质量有无差异。结果 2012年2-7月病历尚未电子化;一般项目填写不规范率、病情记录填写不规范率、救治措施过于简单比例显著低于改进前;2013年2-7月院前急救病例均电子化,改进后无缺少交接记录的病例。病历电子化后一般项目填写、病情记录填写、交接班记录的改进都得到明显提高,与改进前比较具有统计学差异。结论在医院领导重视下,加强对院前急救病历书写重要性的认识和书写规范的培训、加强三基训练、设立奖惩制度、采用院前急救病案模板对提高院前急救的病历质量具有显著效果。
Objective To explore the existing problems of pre-hospital emergency medical records in a hospital, and to analyze whether there are any differences in medical records before and after the improvement measures. Methods In January 2013, targeted improvement measures were adopted to compare the quality of medical records of pre-hospital emergency medical records before improvement (February-July 2012) and improvement measures (February-July 2013). Results The medical records from January to July in 2012 were not yet electronized. The non-standard records of general items, the non-standard records of medical records, the overly simple treatment measures were significantly lower than those before the improvement. In January-July 2013, the hospital emergency cases were all electrified , There is no lack of transfer records after the improvement of the case. General medical records after the entry of electronic items, record of illness records, changes in the transfer records have been significantly improved, with a statistically significant difference compared with before the improvement. Conclusions Under the leadership of the hospital, we should strengthen the training on the importance of writing and writing the precedent emergency medical records, strengthen the training of the three bases, set up the rewards and punishments system, and use the pre-hospital emergency medical record templates to improve the medical record quality of pre-hospital emergency services .