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目的通过分析8470份手术病案中的质量情况,分析手术病案中的书写缺陷,提出相应对策,狠抓病案书写质量。方法根据《病历书写基本规范》和《江苏省住院病历质量判定标准》,对8470份手术病案逐份检查。结果发现病案缺陷的构成为13.20%,其中重度缺陷占总缺陷的13.51%;主要以住院病案首页填写有缺项、实验室及器械检查漏缺和缺传染病疫情报告记录等缺陷因素构成。结论加强医师规范化培训的学习,提高医务人员对病案重视程度,逐级加强病案质控力度,保证病案书写质量。
Objective To analyze the quality of 8470 surgeries, analyze the writing defects in surgeries, propose corresponding countermeasures, and pay close attention to the quality of medical records. Methods According to the “basic norms of medical records” and “Jiangsu provincial medical records quality assessment criteria”, 8470 surgical records were examined. The results showed that the morbidity and defect formation was 13.20%, of which severe defects accounted for 13.51% of the total defects. The main defects were the filling of the first page of the inpatient medical record with missing items, the lack of laboratory and instrument inspection and the record of the outbreak of the missing infectious disease. Conclusion To strengthen the standardization training of physicians, improve medical staff’s emphasis on medical records, step up the quality control of medical records and ensure the quality of medical records.