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目的回顾急诊科死亡档案现状规范急诊死亡病案的管理。方法调取2011年1月至2013年11月在我院急诊死亡的1383例急诊病案,并从建章立制、明晰职责、及时沟通、持续改进、各尽其责等方面进行回顾性分析。结果 1373份病案及时回到挂号室的库中,另有10份通过查找被及时追回。1383例急诊死亡病案无一例丢失。结论通过对急诊死亡病案的专项工作管理,提高了护理人员的法律意识以及责任意识,同时保证病案保存内容完整和对此项管理更加规范,使病案价值得到最大实现。
Objective To review the current situation of death records in emergency department to regulate the management of emergency medical records. Methods A total of 1 83 cases of emergency medical cases that died in emergency department of our hospital from January 2011 to November 2013 were retrieved and analyzed retrospectively from the following aspects: establishing the system, clarifying responsibilities, timely communication, continuous improvement and making every effort. Results 1373 medical records in a timely manner back to the registration room of the library, and another 10 were found through timely recovery. None of the 1383 emergency cases were lost. Conclusion Through the management of the special case of emergency death case, the legal awareness and sense of responsibility of nursing staff are improved. At the same time, the content of the medical record is guaranteed to be more standardized and the management of the case is more standardized so as to maximize the value of the medical record.