论文部分内容阅读
目的通过分析死亡病案医疗护理抢救记录,提高病案书写质量和减少缺陷,降低医疗安全风险。方法分析某院2014年5月-2015年5月共194份死亡病案医疗护理抢救记录,就抢救过程、生命体征的描述、医护记录情况等三个关键点进行分析。结果 194份病案共检出缺陷514处,抢救过程中书写记录不规范244例,占比47.47%,其中抢救人员姓名及职称、抢救起始时间、抢救药物剂量、浓度漏记最为严重;生命体征记录不全232例,占比45.14%;医护记录不一致38例,占比7.39%。结论死亡病案抢救记录缺陷较多,需加强培训和质控,规避安全风险。
Objective To reduce the risk of medical security by analyzing the records of medical care in death cases, improving the writing quality of medical records and reducing defects. Methods A total of 194 cases of medical records of medical treatment in death from May 2014 to May 2015 in a hospital were analyzed. The three key points were the rescue process, the description of vital signs and the records of medical records. Results A total of 194 defects were detected in 194 medical records, 244 cases were not standardized in the rescue process, accounting for 47.47%. Among them, the names and titles of rescues, the starting time of rescuing, the dosage and concentration of rescuing drugs were the most serious. Vital signs 232 cases were incomplete, accounting for 45.14%; 38 cases were inconsistent with medical records, accounting for 7.39%. Conclusion There are many defects in the records of death cases, so training and quality control should be strengthened to avoid safety risks.