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目的找出住院病案质量存在的问题,提出改进意见及措施。方法我院2004年1月至12月的出院归档病案中每月随机抽取约15%的病案4580份检查,作回顾性分析。结果抽检的4580份病案中甲级病历率93%,手术科室及低级职称医师的病历出现缺陷较多。结论各级领导重视,加强医师的法制观念,强化基本功训练,辅以严格的奖罚制度是确保病历质量的关键。
Objective To find out the problems existing in the quality of inpatient medical records and put forward suggestions for improvement and measures. Methods A total of 4580 medical records were randomly selected from 15% of the monthly medical records in the hospital from January to December 2004 for retrospective analysis. Results In the 4580 medical records examined, the rate of Grade A medical records was 93%. There were many defects in the medical records of the operating departments and junior professional physicians. Conclusion The leaders at all levels attach importance to strengthening the concept of doctors’ legal system, strengthening basic skills training, and supplementing with strict reward and punishment systems are the key to ensuring the quality of medical records.