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目的对病案缺项问题进行分析并提出解决方案,保证病案的完整性。方法对2010年1578份缺项病案进行分类、统计和分析。结果病案书写打印不及时、科室缺乏有效管理、对病案质量重要性认识不足、医护人员工作量大等因素是造成病案缺项的主要原因。结论医院信息系统的整合,合理配置医疗资源,提高医生对病案质量重要性认识,加快电子病历试点工作的完成,才能减少甚至消除病案质量的缺项问题,全面提高病案质量。
Objective To analyze the problem of the lack of medical records and propose solutions to ensure the integrity of the medical records. Methods The classification, statistics and analysis of 1578 cases of absence in 2010 were collected. Results Medical records were not printed in time, lack of effective management department, lack of understanding of the importance of the quality of medical records, large workload of medical staff and other factors were the main reasons for the lack of medical records. Conclusion The integration of hospital information system, rational allocation of medical resources, improvement of doctors’ understanding of the importance of medical records and acceleration of the completion of pilot work on electronic medical records can reduce or even eliminate the lack of medical records and raise the overall quality of medical records.