| 心外科医院感染病案书写缺陷与防范 |
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| 引用本文： | 边连朵,张瑜. 心外科医院感染病案书写缺陷与防范[J]. 中华医院感染学杂志, 2010, 20(8) |
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| 作者姓名： | 边连朵 张瑜 |
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| 作者单位： | 首都医科大学附属北京安贞医院病案室,北京,100029 |
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| 摘 要： | 目的了解医院感染病案的质量现状,探讨提高医院感染病案质量的方法。方法根据《病历书写基本规范》要求,检查某三甲医院心外科2003~2008年医院感染病案。结果医院感染病案普遍存在书写不完整、不规范问题,其中缺陷率最高的3项内容依次是术前总结(86.8%)、术前讨论(71.7%)和首页诊断(52.8%)。结论从病历形成前、病历形成过程中对医院感染病历书写进行干预,可以切实提高医院感染病案书写质量,为医院感染的管理提供完善的原始资料,促进医院感染的管理。
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| 关 键 词： | 医院感染管理 病案质量监控 病案管理 |
Quality Control of Medical Records in Cardiovascular Surgery about Management of Nosocomial Infection: Their Limitation and Countermeasure |
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| BIAN Lian-duo,ZHANG Yu. Quality Control of Medical Records in Cardiovascular Surgery about Management of Nosocomial Infection: Their Limitation and Countermeasure[J]. Chinese Journal of Nosocomiology, 2010, 20(8) |
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| Authors: | BIAN Lian-duo ZHANG Yu |
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| Affiliation: | BIAN Lian-duo,ZHANG Yu(Beijing Anzhen Hospital Capital University of Medical Sciences,Beijing 100029,China) |
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| Abstract: | OBJECTIVE To understand the status of medical records concerned with nosocomial infection and to explore methods so as to improve the quality of medical records.METHODS All of nosocomial infection medical records in cardiovascular surgery in a tiatiary care grade A hospital from 2003 to 2008 were studied according to the standard of Specification for Writing of Medical Records.RESULTS Incomplete or non-standard medical records concerned with nosocomial infection were found commonly.The highest rate of pitfa... |
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| Keywords: | Nosocomial infection management Medical records quality control Medical records management |
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