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目的查找基层医院病案管理存在的问题,并进行原因分析,为提高基层医院病案管理质量提供一些依据。方法随机抽取我院2006年1月~2008年1月出院病案进行质量检查,每月和随机在病案室实地查看病案管理情况。结果病案保管存放空间不足致旧病案的调出困难;病案质量中存在病案首页填写不完整不正确、字迹潦草有涂改、医用术语不当、病程记录不全面、小结完成不及时或不符合要求等问题。结论查找医院病案管理中存在的问题并采取积极有效的应对措施,提高病案管理质量,是减少医疗纠纷的有效措施。
Objective To find out the problems existing in the management of medical records in primary hospitals and analyze the causes, in order to provide some basis for improving the quality of medical records management in primary hospitals. Methods Randomly selected the hospital’s medical records from January 2006 to January 2008 for quality inspection. The monthly and random visits to the medical records in the medical record room were performed. As a result, the lack of storage space for medical records resulted in difficulties in the recall of old medical records; in the quality of medical records, there are problems such as incomplete and incorrectly filled in the top of the medical records, altered writings, incorrect medical terms, incomplete medical records, and incomplete conclusions or inconformities. . Conclusion Finding the problems in hospital medical record management and taking active and effective countermeasures to improve the quality of medical record management are effective measures to reduce medical disputes.