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目的通过分析死亡病历书写存在的质量缺陷,寻求解决提升病历书写质量的措施。方法抽查某医院2010年1月1日至2014年12月31日死亡病案137份,对存在质量缺陷回顾性分析。结果 137份死亡病案中检出缺陷病案69份(50.36%),其中各科室缺陷死亡病案分布:内科23例(33.34%)、感染科22例(31.88%)、肿瘤科12例(17.39%)、外科10例(14.49%)、精神科2例(2.90%);共检出缺陷项目20项,缺陷达291频次。结论医院应定期加强医务人员法律与技能培训、历练临床基本功、落实病例讨论制度、加强医护沟通确保内涵质量、实行奖惩责任追究等措施来控制与提升死亡病案质量。
Objective To find out the measures to improve the writing quality of medical records by analyzing the quality defects existing in death medical records. Methods A random sample of 137 death cases of a hospital from January 1, 2010 to December 31, 2014 was retrospectively analyzed. Results A total of 69 cases (50.36%) were detected in 137 death cases. Among them, there were 23 cases (33.34%) in medical department, 22 cases (31.88%) in infection department and 12 cases (17.39%) in oncology department , 10 cases (14.49%) in surgical department and 2 cases (2.90%) in psychiatric department. Twenty items of defects were detected and the number of defects was 291. Conclusion The hospital should regularly strengthen medical and legal personnel training, experience clinical basic skills, implement the case discussion system, strengthen medical communication to ensure the quality of connotation, and implement the rewards and punishments responsible for controlling and improving the quality of death medical records.