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目的院前急救病案终末质量检查,找出存在的缺陷,总结经验,吸取教训,提高院前急救医疗质量,保障医疗安全。方法参照中华医院管理学会急救中心管理分会2003年6月颁布的《院前急救病历书写规范(试行)》本的要求及内容,对2007年我院的1129份院前急救病案归纳为九项逐份逐项进行质量缺陷检查。结果1129份院前急救病案存在着不同程度的缺陷,以病程记录不完整、病史缺陷、体格检查不详细、医生履行告知义务、一般项目填写缺项等问题较为突出。结论院前急救病案书写质量缺陷较多,应站在法律的高度来增强自我保护意识,遵循及时、真实、全面、准确、完整的原则,以严谨的态度认真书写院前急救病案。
Objective To check the final quality of pre-hospital emergency medical cases, identify existing defects, summarize experiences, learn lessons, improve the quality of emergency medical care before hospitals, and ensure medical safety. Methods According to the requirements and contents of the “Pre-hospital Emergency Medical Record Writing Regulations (Trial)” promulgated by the Management Committee of the Emergency Management Center of the Chinese Hospital Management Association in June 2003, 1129 emergency prehospital cases in our hospital were summarized as nine items in 2007. One by one for quality defects inspection. Results There were defects in 1129 prehospital emergency care cases with varying degrees of defects, such as incomplete record of disease course, lack of medical history, lack of detailed physical examination, doctors’ obligation to perform notification, and general project completion. Conclusion There are many defects in the pre-hospital emergency medical record writing quality, and we should stand on the height of the law to enhance self-protection awareness, follow the principles of timelyness, truthfulness, completeness, accuracy, and completeness, and carefully write prehospital emergency medical records with a rigorous attitude.