| 病历书写缺陷分析及对策 |
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| 引用本文： | 陈文权,陈琳玲,林敏.病历书写缺陷分析及对策[J].中国病案,2011,12(10):20-22. |
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| 作者姓名： | 陈文权 陈琳玲 林敏 |
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| 作者单位： | 汕头大学医学院附属第二医院信息科,汕头市,515041 |
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| 摘 要： | 目的分析病历书写缺陷,找出对策,从而提高病历书写质量。方法依据《广东省病历书写规范》制定的评分标准,随机抽取运行和归档病案进行评分评级和缺陷检查,并对缺陷进行统计。结果 734份抽查病历的甲级病历率97.55%,达到要求,外科、运行病历的质量需提高。书写缺陷主要分布在病程记录（33.44%）,缺陷项目主要为缺签名（22.86%）。结论不断完善病历质量控制,提高病历书写水平,促进病历质量持续改进。
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| 关 键 词： | 三级质控 病历缺陷 分析 |
Analysis on Writing Defects of Medical Records and Countermeasures |
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| Chen Wenquan,Chen Linling,Lin Min.Analysis on Writing Defects of Medical Records and Countermeasures[J].Chinese Medical Record,2011,12(10):20-22. |
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| Authors: | Chen Wenquan Chen Linling Lin Min |
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| Institution: | Chen Wenquan,Chen Linling,Lin Min,Information Department of the Second Affiliated Hospital of Shantou University Medical College,Shantou 515041,China |
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| Abstract: | Objective To improve the quality of medical records by analyzing the defects of the medical records and finding countermeasures.Methods Assessing scores and grades and checking defects of running and archive medical records according to medical records writing standard of guangdong province.Results The first rate in 734 medical records is 97.55%.The quality of surgery and running medical records needs to improve.The main defects is in course record(33.44%) and the main item of defect is lack of signature(22... |
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| Keywords: | Three-level quality control Defects of medical records Analysis |
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