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目的:了解住院医师关于心力衰竭患者住院病历的书写合格率和临床诊断率、符合率及存在的问题。方法:病历资料来自首都医科大学附属北京朝阳医院心脏中心2000年1月1日—2000年12月31日的住院心力衰竭病人,包括CCU病房、心内科和心外科。资料完整可供分析的病案438份,统计学处理:主要包括病案合格率心力衰竭诊断符合率存在的问题。结果:病历书写合格率仅55.9％,病历书写中的主要问题是缺乏可靠性和准确性。心力衰竭的诊断率为23.9％,符合率仅36.5％;临床诊断心力衰竭患者与EF值不符合者:高血压+心肌梗塞50％;心肌梗塞30.9％;高血压病7.2％;风心病7.5％;其它扩心病和先心病等4.3％。结论:住院医师病历书写不合格率高达55.9％,应加强住医师病历书写的规范化和语言标准化。心力衰竭临床诊断符合率仅为23％,心脏舒张功能障碍和心肌梗塞时KilliP分级与慢性心力竭的诊断标准有待临床进一步明确规范。
OBJECTIVE: To understand the residency pass rate, clinical diagnosis rate, coincidence rate and existing problems of residents in hospitalized patients with heart failure. Methods: The medical records were from inpatient heart failure patients from January 1, 2000 to December 31, 2000 in Beijing Chaoyang Hospital Heart Center, Capital Medical University, including CCU ward, cardiology and cardiology. Information is complete Analysis of 438 medical records, statistical analysis: including medical record qualification rate of heart failure diagnosis of the existence of the problem. Results: The qualified rate of medical record writing was only 55.9%. The main problem in medical record writing was the lack of reliability and accuracy. The diagnosis rate of heart failure was 23.9% and the coincidence rate was only 36.5%. In patients with clinical diagnosis of heart failure who did not meet the EF value, hypertension and myocardial infarction were 50%, myocardial infarction was 30.9%, hypertension was 7.2%, rheumatic heart disease was 7.5% ; Other heart disease and congenital heart disease 4.3%. Conclusion: Residency medical records writing failure rate as high as 55.9%, should strengthen physician standardized medical records writing and language standardization. Clinical diagnosis of heart failure with a coincidence rate of only 23%, diastolic dysfunction and myocardial infarction KilliP classification and diagnostic criteria for chronic heart failure to be further defined in the clinical specification.