论文部分内容阅读
目的分析聘用医师病历书写质量现状,探讨管理对策,规避医疗纠纷的发生。方法回顾对聘用医师2013年10月至2014年3月独立完成的1799份终末归档病案质依据《病历书写基本规范》及总部病历评分标准进行质控统计、分析存在的缺陷问题。结果甲级病案1656份,占92.05%;乙级病案143份,占7.94%;无丙级病案出现。存在缺陷病案369份,缺陷项达35项,外科系统明显高于内科系统。结论加强病历书写规范与法律知识的学习,提高聘用医师准入门槛,实行岗前培训与末位淘汰制,用奖惩机制激活聘用医师的内在动力,提高病历书写质量。
Objective To analyze the status quo of hiring medical records writing quality, explore management strategies and avoid the occurrence of medical disputes. Methods A retrospective review was made on the quality control statistics of 1,799 end-use medical records filed by hired physicians independently from October 2013 to March 2014 according to the “Basic Medical Records Writing Standards” and the headquarters medical record scoring standard to analyze the existing defects. Results There were 1656 Grade A cases (92.05%), 143 cases of Grade B cases (7.94%) and Grade B cases (No Grade C cases). There were 369 defective medical records and 35 defective items, the surgical system was significantly higher than the medical system. Conclusion To strengthen the study of medical record writing norms and legal knowledge, improve the access threshold for hiring physicians, implement pre-service training and elimination system, activate the internal motivation of employing physicians with reward and punishment mechanism, and improve the quality of medical record writing.