主治医师查房对医疗质量的影响

目的通过主治医师查房考核,加强对病房医疗工作的管理,提高住院患者医疗质量。方法对我院22个临床科室的81名主治医师进行查房考核,并总结分析。结果主治医师查房时忽视体格检查占47.6%;没有修改病历和缺乏教学意识均占33.3%;没有提出患者下一步诊疗措施占28.5%;没有重点询问关键病史占23.8%;特殊检查与治疗分析不全面占23.8%;诊断及鉴别诊断分析不充分占19.0%;未对检查结果进行分析占14.3%。结论加强对主治医师的培训,建立主治医师查房考核制度,提高住院患者的医疗质量。

Influence of Attending Physidan Ward Round to Medical Quality

Objective To strengthen the medical work management, improve the inpatient medical quality by attending ward round examination. Methods Checking the ward round quality of the 81 attending physicians in 22 clinical departments in our hospital, and summarizing the problems. Results 47.6% of the attending physicians ignored physical examination. 33.3% of the attending physicians did not review medical record and lack of the consciousness of teaching. 28.5% of them did not present the next treatment measures. 23.8% of them did not ask critical history. 23.8% of them did not analyze special examination and treatment. 19% of them did not fully analyze diagnosis and distinguishing diagnosis. 14.3% of them did not analyze laboratory results. Conclusion We should strengthen the attending physicians training, establish the relevant examination system to improve the inpatient medical quality.