1728份手术科室病案的缺陷分析与对策

目的探讨手术科室缺陷病案的原因,提出整改措施。方法以病历书写规范为标准,对随机抽查的1728份病案的缺陷进行统计分析。结果在1728份病案中,甲级病案率为97%,乙级病案率为3%;缺陷病案1312份,占75.9%;缺陷项目共1522项。结论加强各级医生对病案书写的责任感和质量意识,强化病案的实时监控与考核,严格病案质量三级把关（出科关、入库关、实时监控关）,确保病案质量持续性改进,减少医疗纠纷和事故。

Defect Analysis and Countermeasures of 1728 Surgery Department Medical Records

Objective To discuss reasons of defects of surgery department medical record,and puts forward some measures for improvement.Methods According to the medical record writing standard,a random sample of 1728 records of the defects are analyzed.Results In 1728 cases,A grade rate was 97%,B grade rate was 3%,1312 medical records have defects,accounting for 75.9% and 1522 items with defect were found.Conclusion We should strengthen medical record writing responsibility and quality consciousness,strengthen medical record real-time monitoring and assessment,carry out the three level control of medical record quality strictly(out of clinical department,into the medical record department,real-time monitoring) to ensure continuous quality improvement,reduce medical disputes and medical negligence.