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目的全面掌握我区各医院基础医、护质量和为部队伤病员服务水平。方法将2010年10月1日-2012年3月31日的所有我区军人死亡病历按专业分布分给各位专家筛选出有较明显缺陷的病历。结果数据显示481例死亡病历中三级医师查房平均占61.66%,病历书写制度落实好的平均占56.3%,医院感染发生率平均为37.26%,主要疾病治疗方案合理充分平均占88.54%,发生压疮的患者平均比例为5.21%,在病历书写、核心制度、基础医疗质量和护理上均存在着不同程度的不足。结论将全区军人死亡病历质控工作列入常态管理,全面提升军区各医院的综合水平。
Objective To comprehensively grasp the basic medical care, the quality of care and the service level for the troops and wounded and sick of all hospitals in our district. Methods All medical records of deaths of military personnel in our district from October 1, 2010 to March 31, 2012 were distributed to specialists according to the professional distribution to screen the patients’ records with obvious defects. The data of the results showed that among the 481 death medical records, the average number of the third-level physicians ward rounds was 61.66%, that of the medical record writing system was 56.3%, that of the nosocomial infection was 37.26% on average, that of the main diseases was about 88.54% on average The average proportion of pressure ulcer patients was 5.21%, there are some deficiencies in medical records writing, core system, basic medical quality and nursing. Conclusion The quality control of medical records of deaths of military personnel in the entire region was included in the normal management and the overall level of all hospitals in the military region was comprehensively improved.