4858份病历单项否决项目的分析

目的通过对单项否决为乙级或丙级病历的项目进行分析，揭示病历质量中重大缺陷之所在，针对主要问题的原因，提出对策和建议。方法抽查住院电子病历4858例，分为非手术科室和手术科室两组，两组之间非甲级病历率、缺陷出现率的差异性对比用x。检验。结果手术科室的乙级病历率2．58％、丙级病历率0．99％，分别高于非手术科室的1．37％、0．04％；手术科室和非手术科室乙级项目最主要缺陷都是缺各类同意书或有效签名（缺陷出现率分别为1．31％和0．64％），以上差异有统计学意义；手术科室丙级项目主要集中在缺麻醉记录单（0．79％），其次是缺手术记录（0．16％）。结论只有各级医务人员、医院管理者对病历质量给予充分的重视，才能减少或杜绝重大缺陷项目，提高病历质量，保障医疗安全。

Analysis on single-item rejection projects of 4858 medical records

Objective To carry out the analysis on the single-item rejection projects of grade B and grade C medical records, uncovering the reason for major defects of the quality of medical records, accordingly offering countermeasures and suggestions. Methods We inspected 4855 cases of electronic in-hospital medical record randomly, dividing them into non-surgical department and surgical department. Then checked the differences between two cases on the ratio of the non-A grade medical records and the occurrence rate of defects using X 2 method. Results In surgical department, the ratio of grade B medical records was 2.58%, the ratio of grade C medical records was 0.99%, higher than those of grade B medical records and grade C medical records of non-surgical department which were 1.37% and 0.04% respectively. The most major defect of grade B projects in surgical department or non-surgical department was the lack of various kinds of letter of consent or valid signatures （the occurrence rate was 1.31% and 0.64% respectively）. The above-mentioned differences were obvious. Grade C projects of surgical department were mainly focused on the lack of anesthesia notes （0.79%）, next on the lack of surgery records （0.16%）. Conclusion Only by fully paying attention to the quality of the medical record from different levels of medical staff and administrative staff of hospitals, can the major defects be reduced or prevented, the quality of the medical record is improved and the medical safety be ensured.