由病案缺陷引发的思考

目的探讨提高病案质量的新措施。方法随机抽取我院2010年7月-2010年10月间的出院病案3000份进行质控分析。结果甲级病案2872份（95.73%）,乙级病案128份（4.27%）,无丙级病案;病案缺陷共5430处,其中临床基础与规范类缺陷占55.49%、医疗安全记录类缺陷占28.71%、诊疗技术与用药类缺陷占15.80%。结论通过对临床医师进行法制和专业知识培训,以提高病案书写能力;利用医院信息管理系统,对病案质量进行实时监控是一种新的病案管理模式;建议进一步完善药物使用等管理制度,确保病历内涵质量的提高;应结合《侵权责任法》进一步规范临床医师诊疗行为。

Viewpoint from Defects Analysis of Medical Records

Objective This paper discusses new countermeasures about medical records quality.Methods 3000 hospitalization medical records are randomly selected from July 2010 to October 2010,had quality analysis.Results There are 2872 class-A medical records(95.73%),128 class-B medical records(4.27%),no class-C medical records;there are 5430 defects,in which defects about clinical basic and standardization accounting for 55.49%,defects about medical safety record accounting for 28.71% and defects about treatment technology and medication accounting for 15.8%.Conclusions It’s advised that the doctors study correlative legal items about medicine and carry through good medical training,so as to enhance quality of medical records writing.The real-time medical records monitoring system might be a new mode of medical records management.Rules must be established such as drug application so as to improve quality of medical records writing.According to Law of Tort liability,it is very important to further standardize the clinicians’ diagnosis and treatment behavior.