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目的提高产科病案出院记录书写质量。方法随机抽取某院2016年4月份300份产科出院病案,按照评价标准进行专项质控,将质控结果录入Excel表中进行统计分析。结果 300份产科病案中281份存在缺陷,缺陷率93.7%,其中最常见的缺陷为出院情况项目,有246份,占82%,主要表现为记录内容不全,无新生儿情况记录或新生儿情况与实际不符。结论产科出院记录存在缺陷,应结合产科专业特点,多措并举,提高出院记录书写质量。
Objective To improve the quality of obstetric medical record discharge records. Methods A total of 300 obstetric patients discharged from a hospital in April 2016 were randomly selected. Quality control was conducted according to the evaluation criteria. The quality control results were entered into Excel for statistical analysis. Results Of the 300 maternity cases, 281 were defective and the defect rate was 93.7%. Among them, 246 were the most common defects, accounting for 82%. The main manifestations were incomplete record, no record of newborn or newborn Not true. Conclusion Obstetric discharge records are flawed, should be combined with the characteristics of obstetrics, take measures to take measures to improve the discharge record writing quality.