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目的了解运行病历质量,加大环节质量监控措施。方法随机抽查正在运行病历1,600份,根据卫生部《病历书写规范》及广西壮族自治区卫生厅《病历书写规范手册》标准要求进行检查。结果1600份运行病历中,未按要求时限完成病历书写72份,占4.5%。结论加强对运行病历质量监控,是保证医疗安全,减少医疗纠纷的前提。
Objective To understand the quality of running medical records and to increase the quality control measures for the links. Methods A random sample of 1,600 medical records was run, and inspections were conducted according to the requirements of the Ministry of Health’s “Writing Rules for Medical Records” and the “Handbook of Medical Records Handbook” of the Guangxi Zhuang Autonomous Region. Results Among the 1600 operating records, 72 were not completed as required, accounting for 4.5%. Conclusion Strengthening the monitoring of the quality of running medical records is a prerequisite for ensuring medical safety and reducing medical disputes.