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目的通过统计某院急诊留观病案的书写质量缺陷,分析急诊留观病案内涵书写现状,为提高医师书写留观病案质量提供依据。方法以《终末病历书写质量检查表》为标准,对某院2015年876份急诊留观病案分类归纳,进行缺陷质量分析。统计学方法使用描述法统计。结果 876份急诊留观病案缺陷频次总计2047次,主要问题存在病案资料不完整(20.91%)、留观病案首页诊疗信息缺陷(11.97%)、入观记录的主诉与现病史不符(11.97%)、病情变化时分析及处理记录或记录存在缺陷(11.53%)以及留观病案中无上级医师诊疗意见或不具体(11.09%)。结论现阶段留观医师在病案内涵书写质量方面还存在很大缺陷,主要是由于急诊多为危急重症患者,来院就诊时病情较重,抢救操作复杂。急诊医师的关注点始终在积极救治患者,抢救生命,从而忽略留观病案的书写质量。需要加强医政管理以及病案质量控制,不断提高急诊留观病案的内涵质量。
OBJECTIVE: To analyze the writing status of medical records in emergent cases by statistics of defects in writing quality of emergency records in a hospital, and to provide basis for improving the quality of medical records. Methods Based on the “Final Medical Records Writing Quality Checklist”, 876 emergency medical records in a hospital were classified and analyzed for quality of defects. Statistical methods use descriptive statistics. Results The total number of 876 emergency cases was 2047 times. The main problems were incomplete medical records (20.91%), the first diagnosis of medical records was 11.97% (11.97% (11.53%) in the analysis and treatment of changes in condition and absence of superior physician’s opinion or unspecified (11.09%) in the observation case. Conclusion At this stage, there are still some shortcomings in the quality of written medical records for the observing physicians. The main reason is that acute patients are mostly critically ill and critically ill patients. Emergency physicians’ attention has always been to actively treat patients and save lives, thus neglecting the quality of written observation cases. Need to strengthen medical management and medical record quality control, and continuously improve the quality of the conception of emergency case.