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目的通过儿科门诊病案记录缺陷分析,制定改进措施,提高病案质量。方法以卫生部《病历书写基本规范》为标准,对7200份儿科门诊病案进行质量检查,应用SPSS17.0统计软件进行缺陷数据统计分析。结果 1224份儿科门诊病案存在缺陷,共出现缺陷次数1540次,缺陷数据进行卡方检验,P<0.01,差异具有显著性。结论通过提高思想认识、强化学习培训、加强质量监控、减轻工作强度提高儿科门诊病案质量。
Objective To analyze the defects of pediatric outpatient medical records and formulate improvement measures to improve medical record quality. Methods Based on the “Basic Norms of Medical Records Writing” of the Ministry of Health, quality control was performed on 7200 pediatric outpatient medical records, and SPSS17.0 statistical software was used to analyze the defect data. Results A total of 1224 pediatric outpatient medical records were found to be defective, with a total number of 1540 defects, and the defect data were analyzed by chi-square test (P <0.01). The difference was significant. Conclusion By raising awareness, strengthening learning and training, strengthening quality control, reducing work intensity and improving pediatric outpatient medical record quality.