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目的分析死亡病案存在的缺陷原因,以制定相应的防范措施,提高死亡病案书写质量。方法采用回顾性死亡病案质量调查法,对某院2014年3月-2017年3月的147份死亡病案进行质量调查,并对发现的缺陷及原因进行分析。结果死亡病案存在的主要缺陷有死亡病例讨论发言雷同、未认真分析死因和未总结经验教训,占26.79%;抢救记录中对生命体征变化、用药及其他抢救措施的描述不具体、错记或漏记,占22.62%;死亡记录中死亡时间与抢救记录、医嘱单、体温单不一致,占17.26%;病案首页主要诊断选择错误,占13.10%。结论死亡病案质量仍存在一定问题,可以通过增强医师的法律意识,严格执行死亡病例讨论制度,加强主要诊断选择的培训,加大质控力度,完善电子病历系统等措施提高死亡病案书写质量。
Objective To analyze the causes of the defects in the death medical records so as to formulate corresponding preventive measures and improve the quality of the written medical records. Methods A retrospective death mass medical record was used to investigate the quality of 147 cases of death in a hospital from March 2014 to March 2017, and the defects and causes were analyzed. Results The main defects of death cases were death cases discussed the same statement, did not carefully analyze the cause of death and did not summarize the lessons learned, accounting for 26.79%; changes in rescue records of vital signs, medication and other rescue measures described specific, wrong or missed Accounting for 22.62%; death records and death records and rescue records, medical orders, body temperature is not inconsistent single, accounting for 17.26%; the main medical record home page wrong choice, accounting for 13.10%. Conclusion There are still some problems in the quality of death medical records, which can be improved by enhancing physicians’ legal awareness, strictly enforcing the system of discussing death cases, strengthening the training of major diagnostic options, strengthening quality control and improving the electronic medical records system.