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目的了解死亡终末病案首页书写质量,分析书写存在的缺陷,探讨提高死亡病历书写质量的有效方法。方法抽取2014年407份死亡病案首页进行缺陷分析,选择6项内容作为评价项目。结果 407份病案首页的主要诊断选择完全正确的318份,占78.13%,其他诊断书写正确314份,占77.15%,入院病情书写正确的329份,80.84%,主要手术书写正确的142份,占手术病历83.04%。结论主要诊断选择错误是影响病案首页书写质量的重要问题,应对临床医师进行管理和培训,以保证医疗质量、确保医疗安全,主要诊断选择是准确绩效评价的前提。
Objective To understand the writing quality of the first page of final death case, analyze the defects of writing, and discuss the effective ways to improve the writing quality of death records. Methods A total of 407 death cases in 2014 were selected for defect analysis and 6 items were selected as evaluation items. Results Of the 407 cases, 318 were correctly diagnosed, accounting for 78.13% of the total, and 314 were correctly diagnosed, accounting for 77.15%. 329 were correctly admitted, 80.84% were correct, 142 were correctly written for major surgery, accounting for Medical records 83.04%. Conclusions The main choice of diagnosis is an important issue affecting the writing quality of the first page of the medical record. The clinician should be managed and trained to ensure the medical quality and ensure the medical safety. The main diagnostic options are the premise of accurate performance evaluation.