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病案室对本院1997年全年眼科住院病案书写质量进行了抽样检查,共随机抽取526份眼科住院病案。 1 存在的主要问题 1.1 病案书写字迹潦草413份,占样本量的78.5％,特别是医生签字无法辨认。 1.2 病案首页项目填写不全589份,占样本量的96.8％。特别是出院记录不及时完成,手术操作名称不全,确诊日期和过敏史不填等,个别病案没有主任签字。 1.3 病案书写专科性不强的217份,占样本量的41.3％。如没有明确的诊断,或诊断主次顺序颠倒,有的中英文混用,乱用符号代替,或者专科术语表达不准确。也有些诊断写缩略词,如:老年性白内障简写为“老白”。病程记录缺乏分析和连续性等。 1.4 病案书写的逻辑性不强385份,占样本量的73.2％。①在书写病案时主诉三要素没有很好的掌握,主诉含糊不清,或用特殊检查结果来代替主诉。②现病史记录不详细。③使用医学术语不规范。 1.5 病案书写的针对性不强198份,占样本量的37.6％。有些病案诊疗计划针对性不强,特别是术前交待针对性不
The medical record room conducted a random inspection of the quality of writing of the ophthalmic inpatients in the hospital in 1997. A total of 526 cases of ophthalmic inpatients were randomly selected. 1 The main problems 1.1 The medical records written 413 scribbled, accounting for 78.5% of the sample size, especially the doctor’s signature can not be identified. 1.2 There are 589 items incomplete on the first page of the case, accounting for 96.8% of the sample size. In particular, the discharge records were not completed in time, the name of the operation was incomplete, the date of diagnosis and the history of allergies were not filled in, and the individual case was not signed by the director. 1.3 217 clinical records were not strong, accounting for 41.3% of the sample size. If there is no definite diagnosis, or if the order of diagnosis is reversed, some Chinese and English are used together, indiscriminate symbols are used instead, or the expression of specialist terms is inaccurate. There are also some diagnostic abbreviations, such as: Old age cataract is abbreviated as “Old White”. The lack of analysis and continuity of the course records. 1.4 The logic of medical record writing is not strong 385, accounting for 73.2% of the sample size. 1 When writing a medical record, the three factors of the chief complaint were not well mastered, the chief complaint was ambiguous, or special test results were used instead of the chief complaint. 2 The current medical record is not detailed. 3 The use of medical terminology is not standardized. 1.5 The medical record writing was not well-targeted in 198 cases, accounting for 37.6% of the sample size. Some medical treatment plans are not well-targeted, especially if preoperative instructions are not addressed.