147份死亡病历质量缺陷分析

目的了解死亡病历质量缺陷问题。方法回顾性分析医院2006年12月~2007年9月死亡病历。结果2006年12月~2007年9月，医院的死亡病历为147人，死亡率为1．64％。死亡病历质量缺陷为：诊断不一致占26．5％，字迹潦草占14．3％，不按时进行死亡讨论占9．5％，缺术后沟通记录占6．8％，上级医生审签不及时占6．8％。结论死亡病历存在的质量问题是由于医务人员未给予足够重视所引发。由于医疗纠纷、医疗赔偿的案例明显增多，医务人员应该重视死亡病历书写的及时性、准确性、完整性，书写合格的病历。

Defect Analysis in Medical Records of the 147 Death Cases

Objective To investigate the defects in the medical records of the death cases. Method Materials of the 147 medical records of the hospitalized death cases between December, 2006 and September, 2007 were analyzed retrospectively for the defects. Result Some defects in these Medical records of the 147 death cases were dominating. Firstly, the diagnoses were inconsistent （26.5%） each other in the first pages, death records, hospitalizing records, and death discussions. Secondly, illegible hand--writings took a rate of 14.3%. Thirdly, 9.5%of death cases were not discussed on schedule. Fourthly,lacks of post--surgery communication account for 6.8%. Fifthly, 6.8% of these medical records were not reviewed and signed by the senior doctors. Conclusion The quality problems existing in the medical records of the death cases are mainly due to the defects of the poorly professional workers, as well as owing to the medical workers who have not placed enough emphasis on the qualities of the medical records. Since the dissensions and reparations of medical affairs are growing obviously, the medical workers should pay more attentions to the timeliness, the accuracy and the intactness of the qualified medical records for self-- protection.