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目的对某院住院病历进行评价,针对评价出的问题,提出对策。方法在该院37个临床科室,以书写病历医师为单位,抽取每人1份终末病历,全院共抽取195份。根据《住院病历质量评价标准(2013年版)》进行评价、分析。结果该院病历存在很多问题,甲级病案率与卫计委规定还有一定差距,病程记录、入院记录存在问题较多。结论加强对实习生、住培医师、年轻医师培训,增强病历规范意识,建立完善的管理体系,进一步提高病历书写质量。
Objective To evaluate the inpatient medical records of a hospital and to put forward countermeasures for the problems that have been evaluated. Methods A total of 195 medical records were collected from 37 clinical departments of the hospital, written medical record physician, and 1 final medical record per patient. According to “hospital medical records quality evaluation criteria (2013 version)” for evaluation and analysis. Results There were many problems in the hospital medical records. There was still a certain gap between Grade A medical records and the regulations of the SSE. There were many problems in the course records and admission records. Conclusion The training for trainees, resident physicians and young physicians should be strengthened, the awareness of medical records should be enhanced, and a sound management system should be established to further improve the quality of medical record writing.