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目的通过对住院病案会诊记录的缺陷分析,为会诊记录质量管理提供可靠的依据和对策。方法选取某三级医院2016年8月1日-2016年8月31日有会诊申请的1270份出院病案,对其会诊记录内容进行质量检查。结果会诊记录存在的主要问题为:会诊目的不明确,占4.9%;与会诊相关的病史、病情发生、发展、诊疗情况及疗效的描述有缺陷,占8.6%;未能体现针对会诊目的的会诊意见,占7.6%。结论会诊记录存在着许多问题,通过加强医师培训,完善医院的三级质控,利用必要的信息技术,可以有效的提高会诊记录质量。
Objective To provide a reliable basis and countermeasure for the quality management of consultation records by analyzing the defect records of inpatient medical records. Methods A total of 1270 cases of discharge from a tertiary hospital from August 1, 2016 to August 31, 2016 were enrolled for consultation and the quality of the consultation records was checked. Results The main problems of the consultation records were as follows: the purpose of the consultation was unclear, accounting for 4.9%; the history of the consultation, the occurrence of the disease, the development, the diagnosis and treatment of the condition and the efficacy of the description were defective, accounting for 8.6%; failed to reflect the consultation for the consultation purpose Opinion, accounting for 7.6%. Conclusion There are many problems in consultation records. By strengthening physician training, improving tertiary quality control of hospitals and using the necessary information technology, the quality of consultation records can be effectively improved.