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目的通过抽查2003年我院归档病案,对照有关标准分析书写质量,了解住院归档病历书写情况,有效提高医疗、护理质量。结果1326份归档病案中1293份为甲级病历,甲级率97.51%。结论住院归档病历书写质量达到三级甲等医院住院归档病案甲级率≥90.0%的要求。
Objective To analyze the writing quality of the hospital in 2003 and analyze the writing quality against relevant standards to understand the writing situation of hospitalized medical records and effectively improve the quality of medical treatment and nursing care. Results Of 1326 archived cases, 1293 were Grade A medical records, with a grade A rate of 97.51%. Conclusion The written quality of hospitalized medical record reached the grade A grade ≥90.0% of grade A hospital inpatient archived case.