CAJ | 학술논문

目的：分析病历中存在的缺陷及其成因，找出解决办法，从而提高病历书写质量。方法：医院质控科对266份出院病历进行检查，对发现的缺陷进行统计、归类、分析。结果：266份病历中共计有缺陷364处，涉及住院处工作人员、临床科室医生、护士及医技科室工作人员。结论：根据缺陷的成因、发现问题，有针对性地组织各相关科室进行学习，从而减少同类缺陷的再次发生，进一步提高病历书写质量。
목적：분석병력중존재적결함급기성인，조출해결판법，종이제고병역서사질량。방법：의원질공과대266빈출원병력진행검사，대발현적결함진행통계、귀류、분석。결과：266빈병력중공계유결함364처，섭급주원처공작인원、림상과실의생、호사급의기과실공작인원。결론：근거결함적성인、발현문제，유침대성지조직각상관과실진행학습，종이감소동류결함적재차발생，진일보제고병역서사질량。
Objective:To analyze the defects in medical records and their causes as well as the solutions in order to improve the writing of medical record .Methods:266 medical records of the discharged were reviewed by the quality control office to locate the defects to be counted, classified and analyzed .Results:364 defects in total in the reviewed 266 discharged medical records involving admission office , doctors from clinic , nurses as well as medical technique office .Conclusion:To organize each relevant office for specified learning in ac-cordance with the causes and problems to the defects so as to reduce the recurrences of the same defects and improve the writing of medical record.