医学信息
醫學信息
의학신식
MEDICAL INFORMATION
2014年
38期
103-103
,共1页
洪雅君%张庆云%龚黛琛
洪雅君%張慶雲%龔黛琛
홍아군%장경운%공대침
病历书写规范%外在质量缺陷%病案质量%对策%单项否决
病歷書寫規範%外在質量缺陷%病案質量%對策%單項否決
병역서사규범%외재질량결함%병안질량%대책%단항부결
Writing guide line of medical record%Extrinsic defects%Medical records quality%Countermeasures,single item rejection
目的探讨病历外在质量缺陷对终末病案质控的影响改进措施。方法根据病历书写基本规范和《南京军区病历质量考核评价标准》，对随机检查的966份出院病历进行查核，并进行统计分析，研究病案外在质量缺陷的类型和原因，提出改进完善的方法措施，有效控制和提高出院病历外在质量。结果随机抽查终末病历966份，查出病程记录中出现外在质量缺陷的病历416份(883处)，占抽查总数的43%，概括出13类外在缺陷并得到及时整改。结论根据病历外在质量缺陷的类型和原因采取积极改进措施，可以消除病案外在缺陷，大大提高病案的质量。
目的探討病歷外在質量缺陷對終末病案質控的影響改進措施。方法根據病歷書寫基本規範和《南京軍區病歷質量攷覈評價標準》，對隨機檢查的966份齣院病歷進行查覈，併進行統計分析，研究病案外在質量缺陷的類型和原因，提齣改進完善的方法措施，有效控製和提高齣院病歷外在質量。結果隨機抽查終末病歷966份，查齣病程記錄中齣現外在質量缺陷的病歷416份(883處)，佔抽查總數的43%，概括齣13類外在缺陷併得到及時整改。結論根據病歷外在質量缺陷的類型和原因採取積極改進措施，可以消除病案外在缺陷，大大提高病案的質量。
목적탐토병력외재질량결함대종말병안질공적영향개진조시。방법근거병역서사기본규범화《남경군구병력질량고핵평개표준》，대수궤검사적966빈출원병력진행사핵，병진행통계분석，연구병안외재질량결함적류형화원인，제출개진완선적방법조시，유효공제화제고출원병력외재질량。결과수궤추사종말병력966빈，사출병정기록중출현외재질량결함적병력416빈(883처)，점추사총수적43%，개괄출13류외재결함병득도급시정개。결론근거병력외재질량결함적류형화원인채취적겁개진조시，가이소제병안외재결함，대대제고병안적질량。
Objective This paper is to explore the influence of extrinsic defects on final quality control and the improving measures.Methods According to the writing guide line of medical records and the evaluating standard of medical records quality of Nanjing military district,a total of 966 discharge medical records was checked randomly and analyzed,the types and causes were studied and the improving measures were put ed out for ef ectively control ing and raising the external quality of discharge medical records.Results Extrinsic defects of 883 items among 416 medical records were picked out from 966 final medical records which occupied 43%of al randomly checked materials.Thirteen kinds of external defects were outlined.Al the defects were corrected timely.Conclusion Taking active improving measures based on the types and reasons of extrinsic deficiency can eliminate the external defects and promote greatly the quality of medical records.
