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目的检查死亡病案的急诊、门诊病历终末质量,找出这些病案存在的缺陷,总结经验,吸取教训,提高急诊医疗质量。方法参照江苏省卫生厅下发的《病历书写规范》第四版急诊、门诊病历的规则、要求,对2004年我院的119份急诊、门诊病历中死亡病案出现的主要问题归纳为病程记录的完整性、病史、体检、辅助检查、诊断、治疗、医生履行告知义务及其他方面八个部分,逐份逐项进行质量缺陷检查。结果119份死亡病案中门诊病历存在着不同程度的缺陷,以医生履行告知义务、病程记录不完整、病史缺陷问题较为突出。对策急诊门诊病案不光是医疗文书,同时也是法律文书,应站在法律的高度来增强自我保护意识,遵循及时、真实、全面、准确、完整的原则,以严谨的态度认真书写急诊门诊病历。
Objective To examine the final quality of the emergency and outpatient medical records of death cases, identify the flaws in these medical records, sum up experience, learn lessons, and improve the medical quality of emergency care. Methods According to the rules and requirements of the fourth edition of the emergency medical records and outpatient medical records issued by the Department of Health of Jiangsu Province, the major problems in the 119 emergency and outpatient medical records in our hospital in 2004 were summarized as the disease course records. Completeness, medical history, physical examination, auxiliary examination, diagnosis, treatment, doctor’s performance of the obligation to inform and other aspects of eight parts, one by one to carry out quality defects inspection. As a result, outpatient medical records in 119 fatal cases had defects of varying degrees. Doctors fulfill their obligation to inform, their course records are incomplete, and their medical history defects are more prominent. Countermeasures The outpatient medical record is not only a medical document, but also a legal document. It should stand on the height of the law to enhance self-protection awareness, follow the principles of timelyness, truthfulness, comprehensiveness, accuracy, and completeness, and carefully write the outpatient emergency medical records with a rigorous attitude.