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目的通过对医师签名存在的缺陷进行分析,了解医师签名缺陷对病历质量的影响,提出以医师签名质量为抓手提高病历质量的对策。方法从日常管理工作中发现的医师签名缺陷入手,随机抽取某医院1 621份2014年终末病历进行质检,统计与医师签名相关的缺陷项目出现次数,分析医师签名缺陷的产生的主观及客观原因。结果经统计,病历质量缺陷项目共出现1 320次,其中与医师签名相关的病历缺陷出现频次为677次(51.29%),其中排在前三位的分别是:(1)病案首页填写缺陷331次(25.08%);(2)病史描述欠规范206次(15.61%);(3)会诊意见未在病程中反映或会诊单书写欠规范62次(4.70%)。结论医师签名在病历质量中起着重要的作用,减少医师签名缺陷可提高病历质量。
OBJECTIVE: To analyze the shortcomings of the physician’s signature, understand the influence of physician’s signature defects on the medical record quality, and put forward the countermeasure to improve the medical record quality with the physician’s signature quality as the starting point. Methods Beginning with the defects of doctors’ signatures found in the daily management, we randomly selected 1 621 medical records of 2014 end-stage in a hospital for quality inspection, counted the number of occurrences of defective items related to physician’s signature, and analyzed the subjective and objective reasons for the physician’s signature defects . Results According to the statistics, a total of 1 320 medical defects were found, of which 677 (51.29%) were related to physician’s signature. Among them, the top three were: (1) (25.08%); (2) 206 cases (15.61%) were under-described in history; (3) 62 cases (4.70% Conclusion Physician’s signature plays an important role in the quality of medical records. Reducing physician’s signature defects can improve the quality of medical records.