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目的探讨分析死亡病历书写中存在的问题,并针对问题给予相关对策,提高病历质量的书写方法。方法选取我院2012年3月~2014年3月的死亡病历1682份,按照相关病历书写管理规范和病历评分表进行质量检查,分析书写中存在问题。结果1682份病程记录书写中,患者入院8 h内完成首次病程记录书写有1539份,占91.5%,入院后48 h内完成副高以上职务医师查房记录有1521份,占90.43%,住院时间超过1个月未有阶段性小结的112份,占20.63%,手术记录中,未在手术后24 h内完成记录有336份,占39.95%,术者未及时签名542份,占64.45%。抢救记录书写中,在抢救患者结束后6 h内完成书写504份,占29.96%,抢救记录未按病程记录发生起止时间记录有252份,占14.98%,死亡病例书写问题中,死亡病例讨论形式化和未认真分析和总结死亡原因占1112份,占66.11%,死亡病例记录死亡时间、首页死亡时间、护理记录死亡时间及抢救记录死亡时间不一致占756份,占44.95%。结论应全面落实死亡病历质量检查,加强医务人员岗位培训,增强法制观念,完善各种医疗安全制度,落实死亡病历原因讨论制度,从根本上杜绝因死亡病历造成的医疗纠纷,提高死亡病历书写质量。
Objective To analyze and analyze the problems existing in the writing of death records and to provide relevant countermeasures to improve the quality of medical records. Methods A total of 1682 medical records of death in our hospital from March 2012 to March 2014 were selected, and their quality was checked according to the management records of medical records and medical records. Results 1682 records of the course of the disease were recorded. Among them, 1,539 were recorded for the first time during 8 hours after admission, accounting for 91.5%. 1521 were recorded within 48 hours after admission, accounting for 90.43% of the total, with a hospitalization time of 90.43% 112 cases did not have stage summary in more than one month, accounting for 20.63%. Of the surgical records, 336 cases were not recorded within 24 hours after operation, accounting for 39.95%. The authors did not sign 542 cases in time, accounting for 64.45%. During the writing of rescue records, 504 copies were written within 6 hours after the rescue was completed, accounting for 29.96%. There were 252 recorded records of the duration of the rescue records, accounting for 14.98% of the records. Among the death cases, the death cases were discussed 1112 or 66.11% of the total number of deaths were not analyzed and summarized. 756 deaths or 44.95% of deaths were recorded on the first death, the first death, the second on death and the second on death. Conclusion It is necessary to fully implement the quality examination of death records, strengthen the training of medical staff, enhance the concept of legal system, improve various medical safety systems and implement the system of discussing the causes of death medical records, fundamentally eliminate the medical disputes caused by the death records and improve the writing quality of death records .