死亡病历书写中存在的问题与防范措施

目的 通过对死亡病历书写中存在的问题给予分析,寻找提高病素质量的书写方法.方法 对689份死亡病案按熙《广东省病历书写与管理规范》以及该院的《中山三院终末病历评分表》进行质量检查和统计分析.结果 死亡病案存在很多书写问题,与医生法律意识和责任心不强、死亡病例讨论存在形式化、上级医生对下级医生指导作用不强等有关.结论 加强对医生的法制教育、增强法制观念,加强医务人员岗位培训、完善各种医疗安全制度,加强对死亡病历的环节质控和终末质控、严格执行死亡病历书写奖惩制度等可有效提高死亡病历的书写质量.

Existing problems of death records writing and their preventive measures

Objective To analyze the existing problems in death record writing and to seek the method to increase the writing quality of medical records. Methods 689 cases of medical records were performed the quality inspection and statistical analysis. Results Many writing problems existed in the medical records, which were related with the light legal consciousness and the poor sense of responsibility of doctors,formalization of death case discussion and the weakened guidance role of senior doctors to junior doctors, etc. Conclusion Strengthening the legal education on doctors, enhancing the legal sense, intensifying the post training, perfecting the various medical safety systems, strengthening the link quality control and final quality control of death records and strictly executing the system of rewards and penalties can effectively increase the writing quality of death medical records.