三级综合医院住院病历书写质量情况调查与总结分析

目的：针对医院病历书写中存在的问题,提出改进的方法。方法：统计山东大学齐鲁医院2009-2010年出院病历117732份,检查人员按照科室10%的出院人数当月抽查,合计抽查11771份病历,其中手术科室抽查6026份、非手术科室抽查5745份。评审标准及依据为卫生部颁发的《医疗机构病历书写规范》、《山东省医疗护理文书书写规范》和《山东大学齐鲁医院住院病历质量评估标准》。结果：手术科室与非手术科室出现＂患者首页基本信息的项目填写不全＂为最多,分别占到5.22%和4.60%,＂报告单、检查单粘贴不规范、不整齐或缺标记＂、＂病历眉栏填写不完整（姓名、页、住院号等）＂是最常见而又容易被忽视的项目。结论：提高病历书写质量,应建立健全医院＂三级＂质控体系;注意环节质量检查,加强与临床业务科室的沟通反馈;抓好住院医师及新入院职工、研究生、进修生岗前培训;加强终末质量监督检查,明确质量评分标准,加大奖罚力度。

Investigation and analysis on medical record quality in tertiary general hospital

Objectives: To find ways on improving medical record quality in accordance with existing problems.Methods: 10% of total 117732 medical records in Shandong University Qilu Hospital from 2009 to 2010 were selected(which are 11771 medical records) by department.In the total 11771 selected medical records,6026 were sugary medical records and 5745 were non-sugary.The standard and foundation of assessment are the regulation of medical record writing in medical institute issued by Ministry of Health,regulation of medical record writing in medical institute issued by Shandong Province and the standard on medical record assessment in Qilu Hospital.Results: The most common problems in both sugary and non-sugary departments are the incompletion of the first page information,which is 5.22% and 4.60% to total selected medical records respectively.The common and easy to be ignored problems are irregular,incompletion of sticking test record and report record,basic information(such as patient’s name,record page and inpatient No.) Conclusions: That establishing hospital three levels quality control system,strengthening process quality test and communication between clinical departments,strengthening training for new staff and graduates and strengthening quality assessment,clearing quality assessment standard and increasing penalty are the effective measures to improve quality of medical record.