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目的探讨病历缺陷对终末病历质控的影响与改进措施。方法根据病历书写基本规范和《南京军区病历质量考核评价标准》,对随机检查的1104份出院病历进行查核,并进行统计分析,研究病案缺陷的项目分布和原因,提出改进完善的方法措施,有效控制和提高终末病历质量。结果随机抽查终末病1104份,缺陷的病历623份(1156处),占56.43%。常见病历缺陷主要是有医嘱缺检查报告单128处,占12.18%、漏填或填错药物过敏126处,占11.99%、局部拷贝、错别(漏)字、病句65处,占6.18%、缺有创诊疗操作记录44处,占4.19%、辅助检查报告医生未签名41处、占3.90%。结论根据病历缺陷的类型和原因采取积极改进措施,可以消除病案缺陷,大大提高病案的质量。
Objective To explore the influence of medical record defects on the quality control of terminal medical records and the improvement measures. Methods Based on the basic medical record writing standards and the Nanjing Military Medical Records Medical Assessment Standards, 1104 randomly selected medical records were checked and statistically analyzed to investigate the distribution and causes of the medical record deficiencies. Measures were put forward to improve and perfect the methods and measures Control and improve the quality of final medical records. Results A total of 1104 cases of terminal illness and 623 defective cases (1156) were randomly selected, accounting for 56.43%. Common medical records defects are mainly lack of inspection report checklist 128, accounting for 12.18%, missing or error-filling drug allergy 126, accounting for 11.99%, local copy, the wrong word, disease sentence 65, accounting for 6.18% There were 44 cases with no record of diagnosis and treatment, accounting for 4.19%, while 41 cases were not signed by the assistant examination report, accounting for 3.90%. Conclusion According to the types and causes of medical record defects, the positive improvement measures can be taken to eliminate the medical record defects and greatly improve the quality of medical records.