论文部分内容阅读
目的:调查分析医院住院患者病案存在的问题。方法:随机选取2009年6月至2012年4月在医院进行住院治疗的1000例患者病案资料,选用统一的调查表进行统计分析。结果:调查的1000份病案资料中,护理记录、医疗记录以及其他方面分别有305份、162份和22份存有较多的质量缺陷,分别占所有病历的30.50%、16.20%以及2.20%,总缺陷率为48.90%。结论:病案资料是有效解决医疗纠纷的重要证据,是维护医患双方切身利益的有力保障,客观准确的记录病案已成为近年来病案质量控制的重要内容。
Objective: To investigate and analyze the existing problems of hospitalized patients in hospitals. Methods: A total of 1000 cases of hospitalized patients in the hospital from June 2009 to April 2012 were selected randomly for statistical analysis. Results: Of the 1000 medical record data, there were 305 nursing records, medical records and other aspects respectively. 162 and 22 had more quality defects, accounting for 30.50%, 16.20% and 2.20% of all medical records respectively, The total defect rate was 48.90%. Conclusion: The medical record data is an important evidence to effectively resolve medical disputes and a powerful guarantee to maintain the vital interests of both doctors and patients. Objectively and accurately recording the medical records has become an important part of medical records quality control in recent years.