CAJ | 학술논문

目的从管理角度剖析病历书写缺陷产生的原因并提出对策。方法随机抽取某医院6120份住院病历，按照《湖北省病历质量考评标准（2010）》给予评价与评分。结果6120份病历中甲级病历率为85.61%；乙级病历率为14.36%；丙级病历率为0.03%。分析书写缺陷产生的原因主要有医务人员对相关法律法规及《病历书写基本规范》不熟悉，部分医师超负荷工作，少数医师人文素质不高，电子病历设计有缺陷以及质量管理体系不健全。结论加强对医务人员医事法律法规教育和《病历书写基本规范》培训，强化医务人员素质教育，合理分配医师工作量，完善电子病历功能建设，健全医院三级医疗质量控制体系，以期持续提升病历书写质量。
목적종관리각도부석병역서사결함산생적원인병제출대책。방법수궤추취모의원6120빈주원병력，안조《호북성병력질량고평표준（2010）》급여평개여평분。결과6120빈병력중갑급병력솔위85.61%；을급병력솔위14.36%；병급병력솔위0.03%。분석서사결함산생적원인주요유의무인원대상관법율법규급《병역서사기본규범》불숙실，부분의사초부하공작，소수의사인문소질불고，전자병력설계유결함이급질량관리체계불건전。결론가강대의무인원의사법율법규교육화《병역서사기본규범》배훈，강화의무인원소질교육，합리분배의사공작량，완선전자병력공능건설，건전의원삼급의료질량공제체계，이기지속제승병역서사질량。
Objective In order to find the right countermeasure to improve the medical records quality. Methods To evaluate and Score the medical records in according to the Hubei province’s evaluation criterion for medical records(2010). Results The percentage of grade A,B,C medical records are respectively 85.61%,14.36%,0.03% of 6120 medical records. The found defects are produced with not familiar with the law and ruler by medical staff,the overwork of some medical staff and the design faults in electric medical record system. Conclusions The training and education should be reinforced in hygienic laws,regulations,basical diathesis,the three-level quality control should reinforced to continual improve medical records quality .