2000份出院病历病案质量的监控分析

目的针对病案中存在的缺陷，分析原因，提出相应的对策，进一步提高病历书写质量。方法根据《中国病案协会住院病历质量检查评价标准》的要求对2008年随机抽取的2000份病历进行终末质控，对存在的缺陷进行全面评价、讨论。结果2000份病案中缺陷病案995份，缺陷例次为3890例次。结论为使病案质量在现有基础上达到更高水平，需要做以下工作：规范病历书写的培训；加强质控力度；定期举办病案展评；加强医德医风和责任心教育。

The Quality Analysis of Two Thousand Discharged Case Files

Objective To analyze the cause of existing defects in medical records and propose corresponding strategies to improve the writing quality of case files. Methods On the basis of evaluation criterion of case file quality formulated by the medical record association in China, two thousand case files in 2008 were drawn randomly to do end quality control and assess the existing defects. Results There were 995 defected medical records in 2000 case files, the defected times were 3890. Conclusions In order to elevate the writing quality of case files, we suggest to train doctors in the medical record, enhance quality control, exhibit and comment the medical record regularly, and reinforce medical ethics and responsibility education.