住院病历书写质量的分析

目的：了解病历书写缺陷，以便采取有效措施提高病历书写质量。方法：回顾性调查3256份住院病历首页、入院记录、病程记录、出院记录、辅助检查、知情同意书、医嘱及基本要求。结果：在所查3256份病历中，首页、出院记录、辅助检查、知情同意书、医嘱的缺陷率非手术科室在22．9％-37．7％，手术科室在27．5％-49．6％；入院记录、病程记录的缺陷率非手术科室82．2％-84．1％，手术科室86．9％～93．9％。结论：病历书写缺陷与临床医师素质密切相关，提高病历书写质量的关键在于强化病历书写意识，加强临床医师素质培养，严格执行病历书写规范。

The Analysis on the Writing Quality of Hospitalized Records

Objective:To learn about the defects in case history writing so as to take effective measures to improve the writing quality of medical records.Method:A retrospective survey was taken on the first page of medical record,admission records,records of disease course and discharge,auxiliary examinations,informed consent form,medical orders and basic requirements included in 3,256 hospitalized records.Result:The defect rate in the first page of medical record,records of discharge,auxiliary examinations,informed ...