住院病历缺陷与潜在性医疗纠纷的调查

[目的]了解病历书写中存在的主要缺陷并且评估潜在的医疗纠纷风险。[方法]对某医院近5年内各科病历随机抽取20%进行抽样调查,根据《广东省病历书写规范》中7大项目及所包含的92个子项目进行常见病历缺陷统计。[结果]最常见是重要内容缺项(48.79%);其次是缺签名(15.56%),修改病历(包括涂改病历)列为缺陷第3位(11.15%)。[结论]为预防潜在的医疗纠纷,该院应加强病历的三级质控。

INVESTIGATION ON DEFECTS IN MEDICAL RECORDS (MR) AND POTENTIAL MEDICAL DISPUTES

[Objective]To observe the main defect items in MR and evaluate the risk of potential medical disputes.[Methods]20% MR in the hospital in recent 5 years were investigated with random sampling.The contents of investigation concerned about 7 main parts and 92 items according to the guide of MR handwriting,published by Health Department of Guangdong Province.[Results]The commonest defect was the loss of some important items(48.79%).No signature in MR ranked the second(15.56%),and the correction of handwriting was the third defect(11.15%).[Conclusion]To prevent potential medical disputes,the quality control of MR in 3 classes should be enforced in this hospital.