| 5684例出院记录缺陷分析 |
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| 引用本文： | 王珩,潘秀莺,李鹏. 5684例出院记录缺陷分析[J]. 中国病案, 2011, 12(4): 18-20 |
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| 作者姓名： | 王珩 潘秀莺 李鹏 |
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| 作者单位： | 1. 安徽医科大学第一附属医院,合肥市,230032
2. 安徽医科大学卫生管理学院,合肥市,230032 |
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| 摘 要： | 目的规范出院记录书写和确保出院记录质量。方法按照安徽省卫生厅《病历书写基本规范》对出院记录的要求,自设调查表,将缺陷分为12项指标,对5684份出院记录常见缺陷调查。结果存在缺陷的记录2554份,缺陷率45%,缺失项目现象严重。结论出院记录质量亟待提高,需解决深层次原因。
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| 关 键 词： | 出院记录 问题 对策 |
Analysis on Defects of 5648 Discharge Medical Records |
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| Wang Heng,Pan Xiuying,Li Peng. Analysis on Defects of 5648 Discharge Medical Records[J]. Chinese Medical Record, 2011, 12(4): 18-20 |
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| Authors: | Wang Heng Pan Xiuying Li Peng |
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| Affiliation: | Wang Heng,Pan Xiuying,Li Peng,First Affiliated Hospital of Anhui Medical University,Health management college of Anhui medical university,Hefei 230032,Anhui Province,China |
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| Abstract: | Objective To ensure the writing quality of discharge medical records.Methods In accordance with the requirement on the discharge medical records by basic norms of medical records writing of the Anhui Province health department and creating our own survey,and dividing the defects into 12 indexes,investigating common defects of 5684 discharge records from a top class and A grade hospital.Results Defect rate is 45%,the departments with operations have higher defect rate and lack of dose usage is in the first p... |
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| Keywords: | Discharge medical records Problems Strategy |
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