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| 2009年湖北省部属、省属和地市三级医院病历质量专项检查归档病历检查结果分析 | |
| 引用本文： | 何艺,张治国,肖黎,彭兆丽,周文庆. 2009年湖北省部属、省属和地市三级医院病历质量专项检查归档病历检查结果分析[J]. 医学与社会, 2010, 23(4): 41-43. DOI: 10.3870/YXYSH.2010.04.017 |
| 作者姓名： | 何艺 张治国 肖黎 彭兆丽 周文庆 |
| 作者单位： | 1. 华中科技大学同济医学院附属同济医院病案科,武汉,430030 2. 华中科技大学同济医学院医药卫生管理学院,武汉,430030 3. 华中科技大学同济医学院附属同济医院医务处,武汉,430030 |
| 摘 要： | 目的:了解湖北省部属、省属和地市三级医院归档病历的质量考核评分情况,分析存在的主要问题,探讨相应的解决方案.方法:根据卫生部和湖北省卫生厅的统一安排,对随机抽取的病历统一按<湖北省医疗机构病历书写规范(2008年版)>进行检查.结果:考核评分结果不符合正态分布,乙级病案率为65.3%,丙级病案率为8.2%.首次病程记录缺内容等是造成丙级病案的主要原因.结论:应经常向医务人员强调病历质量控制要求;进一步规范相关诊疗技术知识,不断提高业务素质:强化个人自查和科室检查的力度,引起医务人员的足够重视. |
| 关 键 词： | 三级医院 病历 |
Analysis of Quality of Medical Records in the Tertiary Hospitals Affiliated to Ministry of Health, Hubei Province or Prefecture-Level Government |
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| He Yi et al Medical Records Section,Tongji Hospital,Tongji Medical College,HUST,Wuhan. Analysis of Quality of Medical Records in the Tertiary Hospitals Affiliated to Ministry of Health, Hubei Province or Prefecture-Level Government[J]. Medicine and Society, 2010, 23(4): 41-43. DOI: 10.3870/YXYSH.2010.04.017 | |
| Authors: | He Yi et al Medical Records Section Tongji Hospital Tongji Medical College HUST Wuhan |
| Affiliation: | He Yi et al Medical Records Section,Tongji Hospital,Tongji Medical College,HUST,Wuhan,430030 |
| Abstract: | Objective:The paper is to analyse quality of medical records in the tertiary hospitals affiliated to ministry of health,Hubei province or prefecture-level government and provide some control methods.Methods:Use the evaluation standards for medical records in Hubei province(2008) to acquire the score.Result:The score is not in accordance with normal distribution.The second level rate of medical records is 65.3% and the third level rate is 8.2%.The deficiency of the first progressive note in medical record is... |
| Keywords: | Tertiary hospital Medical record |
| 本文献已被 CNKI 维普 万方数据 等数据库收录！ | |