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目的探讨死亡病案书写质量对医疗质量的影响。方法对426例死亡病案书写内容进行分析。结果重点分析了病案书写质量对诊断、治疗原则、死亡原因及护理质量四个方面的影响。结论提出了克服病案书写缺陷需要加强的几项措施。
Objective To explore the effect of writing quality of death case on medical quality. Methods The writing contents of 426 death cases were analyzed. The results focused on the analysis of the impact of written case quality on diagnosis, treatment principles, causes of death, and quality of care. Conclusions Several measures have been proposed to overcome the need to strengthen the writing of medical records.