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目的通过分析某院终末病案质量,努力提高病历书写质量和减少病历缺陷。方法随机抽取某院2013年1月-12月6391份终末病案,根据前卫生部《病历书写基本规范》及某院《住院病历质量评审标准》审核评分,统计分析质量缺陷。结果统计终末病案质控的缺陷,累及日常病程记录缺陷共4419例次,占53.62%。结论按照前卫生部《病历书写基本规范》及某院的《住院病历质量评价标准》,规范病案书写质量管理,加强基础质量及环节质量管理,把好病历质量的自我控制关。
Objective To improve the quality of medical record writing and reduce the medical record defects by analyzing the quality of the final medical record of a hospital. Methods A total of 6391 cases of terminal illness from January 2013 to December 2013 in a hospital were randomly selected. According to the “Basic Norms of Medical Records Writing” of the Ministry of Health and the “Evaluation Criteria of Inpatient Medical Records” in a hospital, the quality defects were statistically analyzed. Results Statistics end of the record quality control defects, involving the daily record of a total of 4419 defects, accounting for 53.62%. Conclusion According to the “Basic Norms of Medical Records Writing” of the former Ministry of Health and the “Evaluation Criteria of Inpatient Medical Records” of a hospital, the standardization of quality management of medical records should be standardized and the basic quality and link quality management should be strengthened so as to control the quality of the medical records self-control.