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目的通过对终末病案的质量监控,提高病案书写质量。方法根据山西省卫生厅《病历书写基本规范》的规定,对我院1305份出院病案进行质量检查。结果 482份病案存在缺陷,共出现缺陷次数846次。结论加强医护人员的法律意识和责任心,强化病历书写规范培训,加强运行病历质量监控,提高病历书写质量。
Objective To improve the quality of medical records by monitoring the quality of the final medical records. Methods According to the “Basic Norms of Medical Records Writing” issued by Shanxi Provincial Department of Health, the quality of 1305 discharged cases in our hospital was examined. Results 482 cases of defects exist, a total of 846 times the number of defects. Conclusion To strengthen legal consciousness and sense of responsibility of medical staff, strengthen standardized training of medical record writing, strengthen the monitoring of medical record quality and improve the quality of medical record writing.