抢救记录书写质量分析

目的探讨抢救记录书写缺陷,采取有效措施提高抢救书写质量。方法对277份有抢救记录的出院病案进行检查分析。结果共计304次抢救记录中存在缺陷172次占56.5%,问题条目298条。结论应加强医护人员的法制教育,提高证据意识,规范抢救记录的书写,加强抢救记录质量的监控力度,保证病历的及时性、真实性、完整性。确保抢救记录在医疗纠纷中发挥有效的举证作用。

Defect Analysis on Rescue Record Wring Quality

Objective To explore writing defects of rescue rdcords,and take effective measures to improve rescue records writing quality.Methods Analyzing 277 rescue records of discharge medical records.Results There were 172 defect records in 304 rescue records,accounted for 56.5%.Conclusion We should strengthen the legal education of health care,raise awareness of evidence,regulate the writing of rescue records,strengthen the monitoring strength of the quality of rescue records,and make sure medical records are timeliness,truthfulness and completeness.Ensure that the rescue records play the effective burden proof role in medical disputes.