| 某三甲医院病案书写质量问题分析及对策建议 |
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| 引用本文： | 王珩,潘秀莺,李念念,李鹏. 某三甲医院病案书写质量问题分析及对策建议[J]. 安徽医学, 2010, 31(1): 70-72. DOI: 10.3969/j.issn.1000-0399.2010.01.029 |
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| 作者姓名： | 王珩 潘秀莺 李念念 李鹏 |
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| 作者单位： | 安徽医科大学第一附属医院,合肥,230022;安徽医科大学卫生管理学院,合肥,230032 |
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| 摘 要： | 目的找出病案书写中存在的主要问题，提高病案书写质量。方法对某三甲医院的470归档病案按条目进行检查评分。结果病案书写中存在的主要问题包括：缺项、无签名、记录不及时、现病史过于简单、首次病程录不够简明扼要等。结论加强医师的病案质量意识教育，通过培训提高其病案书写能力，完善制度建设及环节质控是改善现存问题的重要途径。
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| 关 键 词： | 病案质量 书写 问题 |
Problem analysis and suggestions for improvement in medical record writing quality in a 3 A grade hospital |
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| Wang Heng,Pan Xiuying,Li Niannan,et al The First Affiliated Hospital of AnHui Medical University,Hefei ,China. Problem analysis and suggestions for improvement in medical record writing quality in a 3 A grade hospital[J]. Anhui Medical Journal, 2010, 31(1): 70-72. DOI: 10.3969/j.issn.1000-0399.2010.01.029 |
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| Authors: | Wang Heng Pan Xiuying Li Niannan et al The First Affiliated Hospital of AnHui Medical University Hefei China |
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| Affiliation: | Wang Heng,Pan Xiuying,Li Niannan,et al The First Affiliated Hospital of AnHui Medical University,Hefei 230022,China |
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| Abstract: | Objective To find out the main problems in medical record writing and improve the quality of medical records.Methods investigating and rank existing 470 medical records in a 3A grade hospital.Results We summarized the main existing problems in medical record writing are:incomplete;no signature;delay in time;too simple in the depiction of the history of present illness;etc.Conclusion The main way of improving the quality of medical record writing includes emphasizing medical records quality awareness for the... |
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| Keywords: | Medical record quality Writing Problems |
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