CAJ | 학술논문

目的全面掌握我区各医院基础医、护质量和为部队伤病员服务水平.方法将2010年10月1日-2012年3月31日的所有我区军人死亡病历按专业分布分给各位专家筛选出有较明显缺陷的病历.结果数据显示481例死亡病历中三级医师查房平均占61.66%,病历书写制度落实好的平均占56.3%,医院感染发生率平均为37.26%,主要疾病治疗方案合理充分平均占88.54%,发生压疮的患者平均比例为5.21%,在病历书写、核心制度、基础医疗质量和护理上均存在着不同程度的不足.结论将全区军人死亡病历质控工作列入常态管理,全面提升军区各医院的综合水平.
목적전면장악아구각의원기출의、호질량화위부대상병원복무수평.방법장2010년10월1일-2012년3월31일적소유아구군인사망병력안전업분포분급각위전가사선출유교명현결함적병력.결과수거현시481례사망병력중삼급의사사방평균점61.66%,병역서사제도락실호적평균점56.3%,의원감염발생솔평균위37.26%,주요질병치료방안합리충분평균점88.54%,발생압창적환자평균비례위5.21%,재병역서사、핵심제도、기출의료질량화호리상균존재착불동정도적불족.결론장전구군인사망병력질공공작렬입상태관리,전면제승군구각의원적종합수평.
Objective To have a comprehensive grasp of the basic medicine ,nursing quality and the service level for the wounded troops in our district hospitals .Methods According to the distribution of profession ,to classify all the military death medical records from October 1st ,2010 to March 31th 2012 in our district ,and submit them to experts to check out obvious defects from these records .Results Among 481 death cases ,the three level of ward round accounted for an average of 61 .66% ,with well practicable writing system of medical records take average of 56 .3% ,the incidence rate of nosocomial infection for an average of 37 .26% ,the main disease treatment scheme is reasonable and fully accounted for an average of 88 .54% ,the occurrence of pressure ulcers with an average ratio of 5 .21% .There are various degrees of deficiencies in medical records writing ,core system ,the quality of nursing and basic medical treatment .Conclusion To enhance the comprehensive level of military hospitals ,the quality control of military death medical records in the whole region is necessarily to be enrolled in the normal management of hospitals of the whole region .