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目的通过会诊质量监测与管理,分析科间会诊病历存在的问题,探讨提高会诊质量的对策。方法对2256例科间会诊病历进行回顾性分析,就会诊医师资质、会诊原因、会诊目的、会诊意见、病历中会诊意见及执行情况记录、会诊后效果评价记录等因素利用Excel进行分类统计分析。结果全院申请会诊量最大科室为产科,占18.95%,其次为妇科、神经内科、普外科、内分泌科等;会诊原因以出现相应专业症状、体征会诊(占58.91%)最高;会诊医师资质中,主治医师会诊量达1263例,占55.98%;会诊缺陷病历为1410份,占62.5%。讨论应严格执行会诊管理制度及加强会诊管理;完善会诊信息系统等措施,提高会诊质量。
Objective To analyze the existing problems of medical consultation between departments through the monitoring and management of consultation quality and to discuss the measures to improve the quality of consultation. Methods A retrospective analysis was conducted on 2256 medical records of interdisciplinary consultations. Statistical analysis was made on the qualifications of consultation physicians, the causes of consultation, the purpose of consultation, the consultation opinions, the record of consultation in medical records and the implementation records, and the evaluation records after consultation. Results The most department of consultation for the whole hospital was obstetrics, accounting for 18.95%, followed by gynecology, neurology, general surgery, endocrinology, etc. The reasons for the consultation were the highest in consultation (58.91%) with the corresponding professional symptoms and signs. The consultation physician qualification , Attending physician consultation amounted to 1263 cases, accounting for 55.98%; consultation defect medical record was 1410, accounting for 62.5%. Discussion should strictly implement the consultation management system and strengthen consultation management; improve the consultation information system and other measures to improve the quality of consultation.