后补医疗文书产生的原因

目的 通过对后补医疗文书的产生情况进行统计分析,找出改进减少后补医疗文书的方法.方法 本院2015年后补医疗文书登记本共741条文书记录逐条录进Excel进行统计、分析.结果 741份后补医疗文书中665份超过出院后或超过文书报告日期五个工作日,在2015年出院48 876份病案中,后补医疗文书产生率为1.36％.其中超声诊断报告单151份,占22.71％;放射诊断报告单112份,占16.84％;病理诊断报告单69份,占10.38％.结论 确保病案的完整无缺,需从病案形成、管理的各个环节进行全程管理.提高医务人员的法律意识,增强自我保护原则.避免因病案缺陷引发的医疗纠纷给医院或患者带来损害.

Causes of Supplementary Medical Documents

Objective Through statistical analysis of complement medical documents,find out improvement to reduce after filling method of medical documents.Methods 741 document record from medical documents supplement in 2015 were detailed into Excel for statistics and analysis.Results In these 741 supplementary medical documents,665 were later more than five working days after discharge or exceed the document report date.In 48876 hospital medical record in 2015,supplementary medical documents were produced at a rate of 1.36％,with 151 ultrasonic diagnosis report,accounting for 22.71％;112 diagnostic radiology report,accounting for 16.84％,69 pathological diagnosis report,accounting for 10.38％.Conclusion to ensure the medical record intact,we need overall management from all aspects of medical record formation and management.It is necessary to improve the legal consciousness of medical staff,enhance the self-protection principle,so as to avoid medical disputes due to medical record defects or damage.