| 2303份产科病案病程记录缺陷分析与对策 |
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| 引用本文： | 陈丽英,魏秋丽.2303份产科病案病程记录缺陷分析与对策[J].中国病案,2010,11(2):14-16. |
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| 作者姓名： | 陈丽英 魏秋丽 |
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| 作者单位： | 1. 广东省河源市龙川县妇幼保健院病案室,河源市,517300
2. 广东省河源市龙川县计划生育指导站,河源市,517300 |
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| 摘 要： | 目的探讨某医院产科病案病程记录书写存在的主要问题，分析原因，制定对策。方法回顾性分析2007年某医院产科出院病案2303份病程记录书写质量，并对缺陷进行统计剖析。结果检查病案中共有1417份病程记录存在缺陷，占病案数的61．5％，共1527项。结论加强住院医师病历书写的培训，举行专题讲座，提高医务人员法律意识是保证病历书写质量的对策之一。
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| 关 键 词： | 产科病历 病程记录 |
Analysis and countermeasures of defects of 2303 obstetric medical records |
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| Chen Liying,Wei Qiuli.Analysis and countermeasures of defects of 2303 obstetric medical records[J].Chinese Medical Record,2010,11(2):14-16. |
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| Authors: | Chen Liying Wei Qiuli |
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| Institution: | Chen Liying.Department of Medical Records,Maternal , Child Health Care Hospital of Longchuan County,Heyuan City,Guangdong Province,517300 Wei Qiuli.Family Planning Service Station of Longchuan County,517300 |
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| Abstract: | Objective To explore the main problems in obstetric medical records writing and make the corresponding countermeasures.Methods Qualities of 2303 medical records of obstetric patients discharged in 2007 were analyzed retrospectively.Results 1527 defects were found in 1417 medical records,accounted for 61.5% of the total records.Conclusion It is one of the strategies for ensuring the quality of medical records writing,to improve health professionals' awareness towards law,strengthen the training of residents ... |
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| Keywords: | obstetric medical records medical records |
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