3257份首次病程记录书写内容与内涵质量关系的探讨

目的评估首次病程记录的书写状况,探讨其在诊疗中的重要作用与内涵质量的关系。方法随机检查2012年9月-12月期间,1596份出院病案首次病程记录的书写内容和1661份新入院病案首次病程记录完成时限。结果病例特点中无主诉、无现病史、无"三史"、体格检查不全面、无辅助检查分别占29.55%、18.18%、51.51%、59.85%、22.73%;8小时内未完成首次病程记录占10.48%;结论病例特点书写内容不完整,影响拟诊讨论的内涵质量;首次病程记录在病历中具有承上启下的特殊作用,是体现医疗内涵质量的重要窗口。

Investigation of the Relationship between Writing Content and Connotation Quality of 3257 Copies of the First Course Record

Objective To assess the writing quality of the first course record, and investigate its importance role in the diagnosis and treatment of patients and the relationship with the connotation of quality. Methods Checking the writing content of 1596 first course records of discharge and checking the time frame for completion of 1661 first course records of hospitalized during September 2012 and December 2012 randomly. Results For the medical records, no chief complaint records accounting for 29.55 %, no present illness records accounting for 18.18 %, 51.51% records don＇ t have ＂three history＂, 59.85% records show that the physical examination is not comprehensive, no auxiliary examination records accounting for 22.73%. 10.48% of the first course records were not written or completed in 8 hours. Conclusion The characteristics of the cases is incomplete which affects the connotation quality of diagnosed discussion. Because of its writing requirements, the first course record plays the connecting role in medical records, it is an important window to reflect the medical connotation quality.