社区卫生服务机构门急诊病历手册书写质量分析与对策

目的通过社区卫生服务机构门急诊病历手册书写的缺陷分析，制定对策，提高病历质量。方法按《北京市社区卫生工作考核管理办法（试行）》进行检查及统计分析。结果抽查528份门急诊病历手册，有119份病历存在缺陷。结论采取加强全科医生的教育培训，建立健全绩效考核制度，推行责任追究制度，定期检在评估，加强总结交流，持续改进等方法，提高门急诊病历手册书写质量。

Analysis on the Writing Quality of Medical Records Handbooks in Outpatient of a Community Health Service Institution and Relevant Countermeasures

Objective To analyze the defects existing in the medical records handbooks in outpatient of a community health service instilution, formulate relevant countermeasures and improwe the quality of medical records. Methods To check and analyze the medical records handbooks of medical records in outpatient according,to the ＂Appraisal Management Method of Community Health Work in Beijing＂. Results 528 eases of medical records handbooks of medical records were checked randomly, and 119 of these were found existing defects. Conclusions We should adopt methods such as strengthen the education and training of general practitioners, establish and com- plete performance appraisal system, carry out accountability system, strengthen summary and communication and sustainable improvement, thus to improve the writing quality of medical records handbooks in outpatient.