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目的探讨精神科病历书写中存在的主要缺陷,分析原因,提出对策,加强病案质量管理,减少医疗纠纷。方法按照《住院病案质量评分标准》,对2013年11月-2014年11月560份出院病案进行终末质量控制,并对缺陷项目进行统计。结果终末病案质控中发现精神科病案存在不同程度的缺陷,以病程记录缺陷最多,占40.9%。结论加强相关法律法规的培训,规范病案书写质量管理,加强基础质量及环节质量管理,完善奖惩制度实施绩效考核是有效避免或降低医疗风险的关键。
Objective To explore the main shortcomings in the writing of psychiatric records, analyze the causes, put forward countermeasures, strengthen the medical records quality management and reduce medical disputes. Methods According to the “Quality Criteria for Inpatient Medical Records”, the final quality control of 560 discharged medical records from November 2013 to November 2014 was conducted, and the statistics of the defects were conducted. Results There were different degrees of defects in psychiatric cases found in the final quality control of the cases, with the most defects recorded in the course of disease, accounting for 40.9%. Conclusion Strengthening the training of relevant laws and regulations, standardizing quality management of medical records, strengthening basic quality and link quality management, improving rewards and punishments system, and implementing performance appraisal are the keys to effectively avoid or reduce medical risks.