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目的通过对病案质量控制检查中发现的鉴别诊断书写缺陷进行分析,归纳问题特点,寻求解决方法,提高鉴别诊断的书写质量。方法调取某院2016年6月-2016年10月期间的出院病案质控检查记录,将560份缺陷病历进行质量缺陷分类,对其中鉴别诊断书写缺陷进行统计分析。结果 560份缺陷病历中,鉴别诊断书写缺陷53份,占总缺陷率的9.5%,其中鉴别诊断书写简单出现频次最多,达16份,占鉴别诊断缺陷率30.2%,其次为病历拷贝10份,占18.9%,鉴别诊断与诊断关联性差9份,占比17.0%,收集资料不完整、鉴别要点不突出各7份,分别占比13.2%,4份病历中鉴别诊断前后无呼应,占比7.5%。结论鉴别诊断简单及与诊断疾病关联性差和病历拷贝是鉴别诊断书写的主要缺陷原因,需要加强对鉴别诊断意义的认识并提高医学基础知识和提炼归纳能力,强化医务人员对病历书写的重视,自觉提高鉴别诊断书写能力,促进病历内涵质量及医疗质量的共同提高。
Objective To analyze the defects of differential diagnosis found in the examination of quality control of medical records, summarize the characteristics of the problems, seek solutions and improve the writing quality of differential diagnosis. Methods The records of quality control of discharged patients were collected from June 2016 to October 2016 in a hospital. 560 defective medical records were classified into quality defects, and statistical analysis of defects in differential diagnosis was performed. Results Among 560 medical records, there were 53 defects in written diagnosis, accounting for 9.5% of the total. Among them, 16 were simple and easy to distinguish and diagnose, accounting for 30.2% of differential diagnosis, followed by 10 copies of medical records, Accounting for 18.9%, differential diagnosis and diagnosis of poor correlation of 9, accounting for 17.0%, the collection of information is not complete, the main points of identification do not highlight each of the 7, accounting for 13.2%, 4 medical records before and after the differential diagnosis no response, accounting for 7.5 %. Conclusions The differential diagnosis is simple and the correlation between the diagnosis and the disease is poor and medical records are the main defects in the differential diagnosis writing. It is necessary to strengthen the understanding of the differential diagnosis and improve the basic knowledge of medicine and the ability to extract and summarize, and strengthen the medical staff’s emphasis on the writing of medical records. Improve the ability of differential diagnosis and writing, and promote the connotation of medical records quality and medical quality together.