论文部分内容阅读
目的抽查出院病案转科记录书写缺陷类型,分析原因,提出对策。方法依据原卫生部《病历书写基本规范(2010年版)》《军队医院病历书写与管理规则(2010年版)》《电子病案基本规范(试行)》及军区医院病案质量评分标准的细则,抽查出院病案的转科记录书写质量。结果抽检1639份出院病案中转科记录书写的情况,存在缺陷病案263份(263/1639)占16.05%。质量缺陷项目分为22类,共计书写质量缺陷881频次,其中转出记录书写缺陷项目12类,检出缺陷482频次,占总缺陷频次54.71%;转入记录书写缺陷项目10类,检出缺陷399频次,占总缺陷频次45.29%。内科检出书写缺陷379频次(379/881)占总缺陷频次的43%;外科502频次(502/881)占总缺陷频次的57%,转科记录书写质量缺陷外科系统高于内科系统。结论转科记录书写质量与临床医师能力素质、法律意识、责任心、工作态度密切相关。严格岗前培训、强化法律与质量意识、修炼临床基本功、端正工作态度与加大奖惩机制,是提高转科记录书写质量的有效途径。
Purpose To check the types of defects recorded in the records of hospitalized cases, analyze the causes and put forward countermeasures. Methods Based on the detailed rules of “the basic norms of medical record writing and management rules (2010 version)” and “the basic norms of electronic medical record (trial)” of the Ministry of Health and the details of the medical grade quality assessment standard of military hospitals in the Ministry of Health, Transcription record writing quality. Results A total of 1 639 cases of intermission records were recorded. There were 263 cases (263/1639) of them with defective cases accounting for 16.05%. Quality defects were divided into 22 categories, with a total of 881 defects in quality of writing, among which 12 were recorded and recorded defects, 482 defects were detected, accounting for 54.71% of the total; and 10 defects were recorded and recorded, defects were detected 399 frequency, accounting for 45.29% of the total frequency of defects. In the medical department, 379 frequency (379/881) frequency was found to account for 43% of the total frequency of defects; 502 frequency (502/881) frequency was 57% of the total frequency of defects, and quality of surgery was higher in the surgical system than in the medical system. Conclusion The quality of transcribed records is closely related to the ability and quality of clinicians, legal awareness, sense of responsibility and work attitude. Strict pre-job training, strengthening law and quality awareness, practicing clinical basic skills, correcting work attitude and increasing reward and punishment mechanism are effective ways to improve the quality of transcribed records.