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目的探讨分析医院病历书写缺陷率及存在的问题,及时整改以确保病历书写质量。方法检索CNKI、万方数据库、VIP中文数据库,收集相关病案文献。根据异质性检验结果,采用随机效应模型对数据进行合并分析。结果共纳入13篇文献,病案书写缺陷率为35.9%(95%CI:24.0%~47.7%)。甲级病案率为95.7%(95%CI:93.9%~97.4%),病程记录缺陷出现率及缺陷频率均最高,分别为16.2%(95%CI:6.1%~12.3%)、29.6%(95%CI:22.3%~36.8%)。结论甲级病案率较高,医院病案书写中存在缺陷率、缺陷项目多等问题,病程记录缺陷项目出现率及频率最高,需要从医师和病案环节质量控制等方面改善和提高病历书写质量。
Objective To analyze and analyze the defect rate and existing problems of medical record writing in hospitals and make timely rectification to ensure the quality of medical record writing. Methods CNKI, Wanfang database, VIP Chinese database were retrieved and related medical records were collected. According to the results of heterogeneity test, the data were analyzed by random effects model. Results A total of 13 articles were included. The rate of medical record writing defects was 35.9% (95% CI: 24.0% -47.7%). Grade A case-rate was 95.7% (95% CI: 93.9% -97.4%), with the highest incidence of disease recording defects and frequency of defects, accounting for 16.2% (95% CI 6.1% to 12.3%) and 29.6% % CI: 22.3% ~ 36.8%). Conclusions There is a high grade A case rate. There are some defects such as defect rate and defective items in the medical record writing. The incidence rate and frequency of the defect items in the course record are the highest. Therefore, it is necessary to improve and improve the quality of case record writing from aspects of physicians and quality control of medical records.