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目的通过社区卫生服务机构门急诊病历手册书写的缺陷分析,制定对策,提高病历质量。方法按《北京市社区卫生工作考核管理办法(试行)》进行检查及统计分析。结果抽查528份门急诊病历手册,有119份病历存在缺陷。结论采取加强全科医生的教育培训,建立健全绩效考核制度,推行责任追究制度,定期检查评估,加强总结交流,持续改进等方法,提高门急诊病历手册书写质量。
Objective To analyze the defects of handbook of outpatient and emergency medical records of community health service institutions, formulate countermeasures and improve the quality of medical record. Methods According to the “Beijing community health work assessment management practices (Trial)” for inspection and statistical analysis. Results A total of 528 outpatient and emergency medical records were searched and 119 cases were found to be defective. Conclusion To improve the writing quality of outpatient and emergency medical handbook by strengthening the education and training of general practitioners, establishing and perfecting the performance appraisal system, implementing the accountability system, regularly checking and assessing, and strengthening the communication and continuous improvement.