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目的:为了解老年医院病案撰写的质量和存在缺陷因素及提高病案质量能针对性干预。方法:随机抽取我院近两年已入档的住院病案进行回顾性调查,对其评分项目、内容对照病案评分标准逐项进行核实,并统计分析。结果:抽查的95份病案,平均得分(95.07±2.49)分;甲级98.88%,乙级1.05%。其中2010年50份病案平均得分(95.64±2.20)分,甲级100%;2011年病案45份,平均得分94.50分,甲级97.78%,两年的病案统计差异无显著性。结论:医院手写病案评审甲级率较高,与实际不符,存在评审不够细致严格,其结果难以体现病案的真实质量,需对病案撰写和评审者进行规范培训,提高撰写水平,增强法律意识和责任感,预防因病案缺陷而导致医疗纠纷发生。
OBJECTIVE: To understand the quality and defective factors of medical record writing in elderly hospitals and to improve the quality of medical records, we can take targeted interventions. Methods: We randomly selected inpatients admitted to our hospital for the past two years for retrospective investigation, and scored the items and contents of the cases according to the medical records and verified them statistically. Results: 95 cases were randomly selected, the average score (95.07 ± 2.49) points; Grade A 98.88%, Grade B 1.05%. Among them, the average score of 50 medical records in 2010 was 95.64 ± 2.20 and Grade A was 100%. In 2011, there were 45 medical records with an average score of 94.50 and a grade of 97.78%. There was no significant difference in medical records between the two years. Conclusion: The first grade rate of handwritten medical record review in hospitals is high, which is not in accordance with the reality. There is not enough detailed and rigorous appraisal. The result is difficult to reflect the true quality of the medical records. Normative training is needed for the writing and reviewing of the medical records, raising the composing level and legal awareness Responsibility and prevention of medical disputes due to illness defects.