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目的探讨死亡病案中末次抢救记录存在的缺陷,采取有效措施提高死亡病案末次抢救记录的书写质量,确保医疗安全。方法采用回顾性分析法,按照某院《死亡病案质量检查表》《军队医院病历书写与管理规则》《病历书写基本规范》等规范,对2015年全院的214份死亡病案的末次抢救记录进行检查分析。结果 214份末次抢救记录中存在缺陷175条,平均每份病案存在缺陷0.82条,主要存在的缺陷是抢救记录描述不详细占28.00%;家属意见记录不详细占25.14%;上级医师未审签或审签不及时占20.57%,用药剂量、途径等记录太笼统占12.00%。结论从基础、环节、终末质量三个方面,重点规范死亡病案抢救记录的书写,保证抢救记录的及时性、真实性、可靠性、完整性,确保抢救记录在医疗纠纷中发挥有效的举证作用。
Objective To explore the shortcomings of the last rescue records in death medical records and to take effective measures to improve the writing quality of the last medical records of death cases and ensure medical safety. Methods The retrospective analysis method was used to analyze the final salvage records of 214 death cases in 2015 in accordance with the “Quality Checklist of Death Medical Records”, “Military Medical Record Writing and Management Rules” and “Basic Medical Records Writing Standards” Check the analysis. Results There were 175 defects in the last salvage records, with an average of 0.82 defects in each case. The main defects were that the rescue records were not described in detail, accounting for 28.00%; family members’ opinions were not recorded in detail, accounting for 25.14% Audit does not promptly accounted for 20.57%, medication dosage, ways and other records too general accounted for 12.00%. Conclusion From the three aspects of foundation, link and final quality, we should standardize the writing of the record of death records and ensure the timeliness, authenticity, reliability and completeness of the record, so as to ensure that the record of the rescue plays an effective role in supporting evidence in medical disputes .