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目的通过分析院前急救病案的复印情况,提示院前病案质量的重要性,提高书写质量。方法分析2008年1月-2014年12月242份院前急救病案的复印率、复印对象构成、复印目的、复印病案疾病分类。结果病案复印总量和比率呈逐年递增趋势,从2008年7份(0.16‰)上升到2014年的86份(1.91‰);复印对象中所占比例最大的是保险机构,共有107份(44.22%);复印目的所占比例最大的是保险理赔,共有146份(60.33%);复印病案疾病以心跳呼吸停止和意外伤害、交通事故占比最多,心跳呼吸停止有92份(38.02%),意外伤害有85份(35.12%),交通事故有39份(16.12%)。结论院前急救病案复印数量逐年递增,越来越多为社会利用,院前急救机构提高院前急救病历书写及内涵质量,是减少医疗纠纷、确保医疗安全的重要措施。
Objective By analyzing the copy of the pre-hospital emergency medical records, the importance of pre-hospital medical records and the quality of writing are improved. Methods From January 2008 to December 2014, 242 cases of pre-hospital emergency medical records were copied, the object of copying, the purpose of copying and the classification of medical records were duplicated. Results The total number and rate of medical records increased year by year, from 7 (0.16 ‰) in 2008 to 86 (1.91 ‰) in 2014. The largest proportion of photocopies were insurance institutions, with a total of 107 (44.22 (60.33%). Copying of medical records showed that heart-throb stopped breathing and accidental injuries accounted for the largest proportion of traffic accidents, accounting for 92 (38.02%) cases of traffic accidents, There were 85 (35.12%) accidental injuries and 39 (16.12%) traffic accidents. Conclusion The number of pre-hospital emergency medical records is increasing year by year, and more and more are used by the society. Pre-hospital emergency agencies improve the writing and content quality of pre-hospital emergency medical records and are important measures to reduce medical disputes and ensure medical safety.