5636份外科系统终末质控病案的缺陷分析与对策

目的通过分析5636份外科系统病案中存在的缺陷，探讨病案缺陷的成因，提出对策，减少病案缺陷的产生。方法根据《广东省病历书写与管理规范》和我院《终末病历评分表》，对5636份外科系统病案进行终末质控。结果发现病案单项否决缺陷11项，普通缺陷10项。单项否决中缺陷最多的是缺血液制品知情同意书，共86次，占单项否决总数25．59％，普通缺陷最多的是医嘱，共1343次，占普通缺陷总数38．69％。结论提高医务人员对病案的重视程度，加强临床医师规范化的学习，加强病案环节质量控制，保证病案书写质量。

Defect Analysis and Countermeasures of Final Quality Control in 5 636 Surgical Cases

Objective To find out the cause of the defects in medical record, we analyzed the defects in 5 636 surgical cases and tried to work out a solution to reduce the defect number. Methods According to the Guangdong Medical Record Writing and Management Specification and Evaluation Table of Terminal Medical Record of our hospital, we implemented the quality control on the 5 636 surgical medical record. Results It turned out that there were 11 single rejected defects and 10 common defects in all these medical records. Among the single rejected defects, defects from the informed consents of lack-blood products were the most-totally 86 times with 25.59% of all. Among the common defects, defects from doctor＇s orders were the most-totally 1 343 times with 38.69% of all. Conclusion Firstly, raise the attention level on the medical record among the staff in medical personnel. Secondly, put more focus on the specification study of clinicians. Thirdly, strengthen the quality control on the process of generating medical record. Moreover, ensure the writing quality of medical records.