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目的通过对病案终末质量监控,提高病案书写质量,同时提高医院管理水平。方法根据卫生部《病历基本书写规范》和《江苏省住院病历质量判定标准[2009年版]》,对近3年出院病案进行质量评定。结果 34,251份病案中有5154份存在缺陷,缺陷率15.0%。结论加强医务人员的法律意识和责任心,强化病历书写规范,提高病案书写质量和管理水平。
Objective To improve the quality of hospital records by improving the quality of final medical records. Methods According to the Ministry of Health “basic medical records specification” and “Jiangsu Provincial Medical Records Quality Criteria [2009 Edition]”, the quality of discharged medical records in the past 3 years. Results Of the 34,251 cases, 5154 were defective and the defect rate was 15.0%. Conclusion To strengthen the legal awareness and sense of responsibility of medical staff, strengthen the writing of medical records, improve the quality of written medical records and management level.