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目的加强围手术期病历质量管理,提高病历内涵质量。方法制定围手术期病历质量监控表,对终末手术病案质量进行监控。结果核心制度执行不利,术前风险评估不到位,预防性使用抗生素级别偏高、时间偏长。结论应进一步加强医师业务素质的训练,加强抗生素的使用管理,推进临床路径的开展,以提高围手术期病历质量,保障医疗安全。
Objective To strengthen the perioperative medical records quality management and improve the quality of medical records. Methods Perioperative medical record quality control table was established to monitor the quality of the final surgical record. Results The implementation of the core system is unfavorable, preoperative risk assessment is not in place, the level of preventive use of antibiotics is high, and the time is long. Conclusion It is necessary to further strengthen the training of physicians’ professional qualities, strengthen the management of the use of antibiotics and promote the development of clinical pathways so as to improve the quality of perioperative medical records and ensure medical safety.