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目的调查分析某院麻醉术前访视记录单质量,完善病历书写质量,降低医疗隐患。方法随机调取2015年1月~2015年6月1200份手术病历,按病历书写规范进行质量分析。结果 1200份手术病历中麻醉术前访视记录单存在缺陷547份,占45.58%,主要分布在并存疾病与麻醉相关的辅助检查结果中,分别占20.19%与17.85%;科室以甲状腺外科、头颈外科最多,分别占52.44%与48.6%。结论通过增强麻醉术前访视记录单的监控,促进麻醉术前访视制度的落实以降低手术风险。
Objective To investigate and analyze the quality of visiting records before anesthesia in a hospital, improve the writing quality of medical records and reduce the medical risks. Methods A total of 1,200 surgical records from January 2015 to June 2015 were randomly collected and analyzed according to the medical records writing standard. Results There were 547 cases (45.58%) of the 1,200 cases with preoperative anesthesia visit records, accounting for 20.19% and 17.85% of the total respectively. The departments of thyroid surgery, head and neck Surgery up, accounting for 52.44% and 48.6%. CONCLUSIONS: To improve the preoperative anesthesia visit system and to reduce the surgical risk by enhancing the surveillance of preoperative anesthesia visit records.