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为了提高门诊病案书写质量,降低门诊就诊医疗纠纷,随机抽查某院门诊病案357份,按照门诊病案书写质量评分标准进行评分。抽查结果:大部分门诊病案基本合格,不同性别、不同年龄、职称高低门诊医师的门诊病案书写质量比较均无显著差异,但是门诊病案规范化书写质量与门诊病案的管理仍是目前医院存在普遍和突出缺陷。
In order to improve the quality of outpatient medical record writing and reduce outpatient medical treatment, 357 outpatient medical records were randomly selected and scored according to the outpatient medical records writing quality grading standards. Sampling results: Most of the outpatient medical records were basically qualified, and there was no significant difference in outpatient medical records between different sexes, different ages and titles, but the standardization of outpatient medical records and management of outpatient medical records were still common and outstanding defect.