3 000份门急诊及留观病历的质量分析

目的：探讨门、急诊及留观病历的质控与管理方法，适应当前医疗市场需要。方法：随机抽检我院2000年1月至2001年11月门诊、急诊、留观病历各1000份，对其内容进行分析，寻找问题，进行分类，分析成因，提出对策。结果：门诊病历缺陷总结为12类，急诊病历存在10个方面的问题，留观病历缺陷归纳为10类。结论：规定门诊、急诊及留观病历质量控制的具体内容和目标有助于提高门诊医疗文件的管理质量。

Quality Analysis of 3 000 Cases of Outpatient,Emergency and Observance Medical History

Objective:To explore the method of quality control and administration on outpatient medical history and meet the demand for present medical market. Methods: 1 000 cases of outpatient medical history, 1000 cases of emergency medical history and 1 000 cases of observance medical history were randomized during 2000.1-2001.12. In these medical histories, the content were analyzed, the defects were sought and classified, the causes of these defects were discussed and the methods on eliminating the defects were explored. Results: 12 kinds of the defects were summarized in outpatient medical history. There were 10 problems in emergency medical history and 10 kinds of the defects in observance medical history. Conclusion: The regulation of the content and aim in quality control and administration on outpatient, emergency and observance medical history were helpful to improve administration quality of patients' medical documents.