某院住院病历质量问题探究

目的通过分析住院病历质量缺陷的分布情况,制定相应的改进措施,从而不断提高医疗质量。方法随机抽取住院病历1 862份,组织4名专家审查病历质量存在的主要问题,分析产生的原因。结果共发生落实制度方面的缺陷24例次,诊疗质量缺陷30例次,病历书写质量缺陷31例次。结论医院在质量管理方面做得还不够到位,内涵质量有待提高。要通过加强教育培训,强化各环节质量控制和建立科学评价机制,提升医疗质量管理水平。

Inpatient Medical Records Quality in Certain Hospital

Objective Analyzing the inpatients medical records quality defects, to formulate appropriate countermeasures, so as to raise the medical quality. Method 1862 cases of inpatients were randomized for the in- vestigation. Four experts were organized to review the quality of medical records, and analyze the main problems and its causes. Results There are 24 defects in system implementation, 30 defects in diagnosis and treatment quality ,31 defects in the writing quality of medical records. Conclusions Hospital quality management has not done enough, and its connotation quality should be improved. In order to elevate the medical quality ,we suggest to train doctors in the medical record, enhance quality control in every medical procedure, and establish a scientific e- valuation system for the quality control of each work links.