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目的针对内科住院病历书写中存在的问题进行调查与分析,提出改进的策略。方法按照2010年3月卫生部颁布的《病历书写基本规范》和《住院病案(终末)书写质量检查表》对其进行终末病案质控,并根据调查结果进行分析。结果2014年1月~3月和2013年1月~3月我院内科住院病案分别为1992份和1721份,甲级病案率分别为94.2%和87.8%,发现缺陷病案1029份,占28.7%。结论 2014年1月~3月和2013年1月~3月相比,我院内科病房住院病案甲级病案率有所提高。院领导应加强对病案质量的重视,认真落实三级医师责任制,统一标准、规范培训,加强病案质量控制管理以及全院医务人员的法律意识,从而促进内科住院病历书写质量及医疗质量的提高。
Objective To investigate and analyze the existing problems in medical inpatient records writing and put forward the improvement strategies. Methods According to the “Basic Norms of Medical Record Writing” and “Inpatient Medical Record (Final) Writing Quality Checklist” promulgated by the Ministry of Health in March 2010, the final condition was controlled and analyzed according to the survey results. Results From January to March 2014 and January to March 2013, the medical records of inpatients in our hospital were 1992 and 1721 respectively, the first grade cases were 94.2% and 87.8% respectively, and 1029 cases were found defective, accounting for 28.7% . Conclusions Compared with January-March 2013 in January-March 2014, Grade A medical records of medical wards in our hospital have been increased. Hospital leaders should strengthen the emphasis on the quality of medical records, conscientiously implement the three levels of physicians responsibility system, standardize and standardize training, strengthen the medical records quality control management and legal awareness of medical staff in the hospital to promote the medical inpatient writing quality and medical quality improvement .