出院记录质量专项检查问题分析及对策

目的对住院病案的出院记录部分存在的问题进行分析,提出相应对策以提高病案质量。方法依据国家卫生部颁发的《病历书写基本规范（试行）》的有关规定,结合我院病历书写要求对613份归档病案进行出院记录质量的专项检查,检查包括出院记录中的一般情况、入院情况、入院诊断、诊疗经过、出院情况、出院后注意事项以及医师签名等共12项内容。结果问题较多的是出院时无专科检查的占73.90%,出院诊断与病案首页、入院记录中的最后诊断不一致的现象占33.44%。结论通过出院记录专项检查,更加体现出病案质量检查从形式检查重心向诊疗行为干预检查转移的重要性,从而进一步提升病案质量控制的内涵。

Problems analysis and relevant countermeasure to the special quality inspection of discharge records

Objective To analyze the problems existing in the discharge records of medical records,then propose relevant countermeasure to improve the quality of medical record.Methods According to relevant provisions of medical record writing fundamental rules issued by the ministry of health,taking a special inspection to the quality of 613 discharge records combined with the writing rules of our hospital.The inspection includes 12 terms: general condition,admitting condition,admitting diagnosis,treatment,discharge condition,discharge matters need attention and signature of doctors.Results The most common was lack of special inspection while discharging which took 73.9%,and the final diagnosis in discharge diagnosis,homepage and admitting record was inconsistent took 33.44%.Conclusion The importance of treatment intervention inspection was reflecting more through the special quality inspection of discharge records,and improving the intension of medical record quality control.