首页 | 本学科首页   官方微博 | 高级检索  
     

11836份病案书写质量的分析与改进建议
引用本文:龚仁俊,曹良玉,汪俊. 11836份病案书写质量的分析与改进建议[J]. 安徽卫生职业技术学院学报, 2013, 12(4): 12-13
作者姓名:龚仁俊  曹良玉  汪俊
作者单位:龚仁俊 (金寨县人民医院,安徽,237300); 曹良玉 (金寨县人民医院,安徽,237300); 汪俊 (金寨县人民医院,安徽,237300);
摘    要:目的:探讨如何提高病案书写质量。方法:对某医院11836份病案质量检查结果进行问题分析。结果:病案书写中存在主要问题包括:首页缺项、签名不及时、核心制度记录不完善或不规范、医嘱停改不及时等。结论:加强各临床科室负责人病案质量管理意识和医师的病案书写质量意识教育。完善制度建设及加强各环节质量控制,是改善现存问题的重要途径。

关 键 词:病案书写质量  病案缺陷  对策

Analysis and Improvement Suggestions on 11836 medical record writing quality
The People 's Hospital of Jinzhai County,Jinzhai,Anhui GONG Ren-jun,CAO Liang-yu,WANG Jun. Analysis and Improvement Suggestions on 11836 medical record writing quality[J]. Journal of Anhui Heaith Vocational & Technical College, 2013, 12(4): 12-13
Authors:The People 's Hospital of Jinzhai County  Jinzhai  Anhui GONG Ren-jun  CAO Liang-yu  WANG Jun
Affiliation:The People 's Hospital of Jinzhai County, Jinzhai 237300, Anhui GONG Ren-jun,CAO Liang-yu,WANG Jun
Abstract:Objective:study how to improve the quality of medical record writing.Metho&Inspect and analyse every inspection result about medical record quality into 11836 medical records.Result:The main problems existing in the medical record writing include incompletement of the home page items,delay of the signature,incompletement and un- standard of the record about the core system, delay of the discontinuance and change on the doctors'orders and so on. Conclusion:To strengthen the management consciousness of every head of the clinical departments for the medical record quality and the doctors' consciousness education on the quality through trainings and perfect the system construction an taut approach to improving the existing problems. medical record writing quality on the medical record d strengthen quality control of each link are an impor-
Keywords::Medical record writing quality  Medical record defects  Countermeasures
本文献已被 维普 等数据库收录!
设为首页 | 免责声明 | 关于勤云 | 加入收藏

Copyright©北京勤云科技发展有限公司  京ICP备09084417号