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目的评估首次病程记录的书写状况,探讨其在诊疗中的重要作用与内涵质量的关系。方法随机检查2012年9月-12月期间,1596份出院病案首次病程记录的书写内容和1661份新入院病案首次病程记录完成时限。结果病例特点中无主诉、无现病史、无“三史”、体格检查不全面、无辅助检查分别占29.55%、18.18%、51.51%、59.85%、22.73%;8小时内未完成首次病程记录占10.48%;结论病例特点书写内容不完整,影响拟诊讨论的内涵质量;首次病程记录在病历中具有承上启下的特殊作用,是体现医疗内涵质量的重要窗口。
Objective To assess the writing status of the first course record and to explore the relationship between the important role in quality of diagnosis and treatment. Methods Randomly examining the writing of the first course record of 1596 discharge cases and the completion time of the first course record of 1661 newly admitted cases during September-December 2012. Results There was no chief complaint, no history of medical history, no history of the three histories, incomplete physical examinations, and no auxiliary examinations accounted for 29.55%, 18.18%, 51.51%, 59.85% and 22.73% respectively. For the first time within 8 hours The records of the course of diseases accounted for 10.48%. Conclusion The characteristics of the cases were incomplete, which impacted the connotation quality of the proposed diagnosis. The first course record had the special function of connecting with the medical records and was an important window reflecting the quality of medical connotation.