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目的通过分析死亡病案首次病程记录书写存在的缺陷,寻求改进措施,进一步提高死亡病案内涵质量,保障医疗安全。方法采用回顾性死亡病案书写质量分析法。按照《军队医院病历书写与管理规则》《病历书写基本规范》及某院《死亡病案质量检查表》的相关要求,对某院2015年1月至12月214份死亡病案中的首次病程记录书写存在的问题进行分析,使用描述性统计方法。结果 214份死亡病案首次病程记录主要存在的问题是病例特点未认真归纳提炼占36.15%,缺鉴别诊断或讨论不充分占23.85%,诊疗计划不具体,无针对性占16.15%。结论加强医务人员培训,夯实“三基”知识,充分发挥科级质控作用,提高主治医师教学查房质量,坚持会议通报与病案展评制度等措施,对提升死亡病案内涵质量有重要意义。
Objective By analyzing the shortcomings of the writing of the first course record of death medical records, seeking for improvement measures, further improving the quality of medical records, and ensuring medical safety. Methods Retrospective death record writing quality analysis method. According to the “Military Hospital Medical Record Writing and Management Rules,” “Basic Medical Records Writing” and a hospital “Death Medical Records Quality Checklist” of the relevant requirements of a hospital in January 2015 to December 214 death records in the first course of writing record Analyze the problems and use descriptive statistics. Results The main problems of the 214 records of the first death course were the characteristics of the cases which were not conscientiously extracted and accounted for 36.15%, the lack of differential diagnosis or inadequate discussion accounted for 23.85%, the diagnosis and treatment plan was unspecific and the non-targeted rate was 16.15%. Conclusion It is of great importance to improve the quality of the medical record of death by strengthening the training of medical staff, consolidating the knowledge of “Three Basics”, giving full play to the quality control of department level, improving the quality of attending physician ward rounds and insisting on meeting notification and medical record exhibition evaluation system significance.