术前病历质量管理评价

目的 了解术前手术病历书写存在的主要问题及质量控制的重要作用。方法 随机抽取术前手术病历共4024 份，应用术前手术病历专项质控表进行质控，比较质控前后缺陷病历数及平均病历缺陷率。结果 质控前缺陷病历数746 份，占总抽查病历数的40.00%。质控后缺陷病历数208 份，占总抽查病历数的9.63%，缺陷病历数对比有统计学意义（P =0.000），术前检查、术前医患沟通、手术安全核查及风险评估、术前医嘱、术前病程的平均病历缺陷率均降低，并有统计学意义（P =0.000）。结论 持续加强术前手术病历的质量监控，可以提高术前手术病历书写质量。

Preoperative Records Quality Management Evaluation

Objective To understand the main problems existed in preoperative operation records and the important role of quality control. Methods Randomly selecting 4024 preoperative surgical medical records, and using preoperative surgical medical records special quality control table to exam them. To compare the number of defects medical record and average defect rate before and after quality control. Results The number of defect medical ~ecords before quality control is 746, accounting for 40% of the total number of records. The number of defect medical records after quality control is 208, accounting for 9.63% of the total number of records. The comparison has statistical significance （P=0.000）. The average defect rates of preoperative examination, preoperative physician-patient communication, operation safety verification and risk assessment, preoperative medication, preoperative course record have declined with statistical significance （P = 0.000）. Conclusion Continue to strengthen the quality control of preoperative operation records can improve the preoperative operation records quality.