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目的通过对出院病案回收中质量检查,对存在的问题缺陷进行归纳分析,为规范出院病案质量管理提供参考。方法对某医院2014年7月-9月33673份出院病案存在的缺陷问题进行有效数据统计,分析缺陷原因,制定干预措施。结果 33673份出院病案,主要问题条目3620项,主要分布在外科,缺陷率占85.49%。干预后病案缺陷问题发生率总体呈下降趋势,平均下降了0.06个百分点。结论加强医院病案管理责任制,增强环节中病案质量监控与沟通,强化各级医师的质量意识及风险意识,规范病案书写质量及培训机制,是促进全院病案质量提高的有效措施。
OBJECTIVE Through the quality inspection of the discharged medical records, the existing problems and defects were summarized and analyzed, which provided reference for standardizing the quality management of discharged medical records. Methods The data of 33673 discharge cases in a hospital from July to September in 2014 were analyzed statistically with valid data to analyze the causes of the defects and make interventions. Results 33673 cases of discharge, the main problem items 3620, mainly in the surgical, defect rate accounted for 85.49%. After the intervention, the incidence of the problem of medical record was generally declining, with an average decrease of 0.06 percentage points. Conclusion It is an effective measure to enhance the medical record management system in hospitals, enhance the monitoring and communication of medical record quality, strengthen the quality awareness and risk awareness of physicians at all levels, and standardize the quality of medical record writing and training mechanisms.