| 582份手术科室运行病历存在的问题及对策 |
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| 引用本文： | 王世彤,楚恒群,张力平,王炜杰.582份手术科室运行病历存在的问题及对策[J].中国病案,2009,10(12):17-18. |
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| 作者姓名： | 王世彤 楚恒群 张力平 王炜杰 |
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| 作者单位： | 河北医科大学第二医院病案室,石家庄市,050000 |
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| 摘 要： | 目的探讨手术科室运行病历中存在的主要问题,分析原因,制定对策。方法制定了运行病历检查表,随机抽查2008年9月-2009年4月外科运行病历582份并进行统计。结果存在的主要问题是：入院记录中家族史不全、婚姻史婚育史不全、病程记录医师签名不及时、医嘱签名不及时、手术记录术者不及时签名、手术知情同意书无本院医师签名等。结论为了提高病案书写质量,建立病案质量检查、反馈制度,将病案质量的检查重心从终末质量监控转移到环节质量检查上来。
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| 关 键 词： | 运行病历 存在问题 对策 |
Problems and Countermeasures of 582 Medical Records in Surgery Departments |
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| Wang Shitong,Chu Hengqun,Zhang Liping,Wang Weijie.Problems and Countermeasures of 582 Medical Records in Surgery Departments[J].Chinese Medical Record,2009,10(12):17-18. |
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| Authors: | Wang Shitong Chu Hengqun Zhang Liping Wang Weijie |
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| Institution: | (Medical Record Office of Second Hospital of Hebei Medical University,Shijiazhuang 050000 ) |
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| Abstract: | Objective To make strategies by the analysis of medical records used for surgery.Methods A total of 582 medical records in surgery departments were randomly investigated by inspection table of medical records in our hospital from Sep,2008 to Apr,2009.Results The primary problems were summarized mainly as follows： incomplete family history in admission record,incomplete marriage and birth history,physician＇s delayed signature in medical orders and records of course,untimely signature of operation recorders and loss of physician＇s signature in operation informed consent.Conclusion To improve the quality of medical records,it is important to establish quality inspection and feedback system of medical records and focus on the quality control of links instead of terminals. |
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| Keywords: | medical records existent problems countermeasures |
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