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目的通过分析死亡病历书写缺陷,评价质量关键环节管控效果。方法对4年的死亡病历进行终末质量检查,应用PASW Statis-tics18软件进行统计分析。结果出院病历与死亡病历缺陷数卡方检验结果分别为χ2=99.498、χ2=64.328、χ2=64.565、χ2=47.690(P<0.01)。在病历缺陷评定无显著差异的情况下,死亡病历书写质量低于总体病历书写质量,OR=2.071,死亡病历包含出现缺陷的风险约是一般病历的2倍。出院病人甲级病案率与死亡率呈明显相关。结论提高病历质量是提高医疗质量和减少住院死亡率的有效措施。
Objective To analyze the defects of writing on death records and evaluate the control effect of key links in quality. Methods The end-stage quality of 4-year death records was examined by PASW Statis-tics18 software. Results The chi-square test results of discharge medical records and death records were χ2 = 99.498, χ2 = 64.328, χ2 = 64.565, χ2 = 47.690 (P <0.01). Under the condition of no significant difference in the evaluation of the medical records, the quality of the written medical records of death was lower than that of the overall medical records, OR = 2.071. The risk of the death records containing the defects was about twice that of the general records. Discharged patients Grade A case rate and mortality were significantly related. Conclusion Improving the quality of medical records is an effective measure to improve the quality of medical care and reduce the in-hospital mortality rate.