中华医学教育杂志
中華醫學教育雜誌
중화의학교육잡지
CHINESE JOURNAL OF MEDICAL EDUCATION
2014年
5期
785-787
,共3页
刘佳梅%王红石%李胜楠%侯冉%李季香%卢予倩%张麟
劉佳梅%王紅石%李勝楠%侯冉%李季香%盧予倩%張麟
류가매%왕홍석%리성남%후염%리계향%로여천%장린
普通门诊病历%病历质量%继续医学教育
普通門診病歷%病歷質量%繼續醫學教育
보통문진병력%병력질량%계속의학교육
General out-patient medical records%Quality of medical records%Continuing medical education
目的 了解临床医师普通门诊首诊及复诊病历合格率,分析不合格原因,提出改进建议.方法 收集首都医科大学附属北京朝阳医院心内科2013年7月8日~7月12日门诊病历,每天随机抽查门诊接诊医师书写的门诊首诊病历10份,连续5天共50份,并一对一追踪其复诊病历.同期计算门诊全天接诊患者总数及接诊医师人数,并记录书写一份合格普通门诊病历的时间.结果 普通门诊首诊病历合格率44.0%,复诊病历合格率45.7%.首诊病历不合格的主要原因为缺项,复诊病历不合格的主要原因为缺乏对首诊治疗或诊断的反馈性记录.连续5天患者的就诊人数平均为(812±85)人次/天,接诊医师平均每天接诊145例患者,每3.3分钟接诊1例患者.合格首诊病历和复诊病历的书写时间分别为(11.7±1.2)分钟和(10.7±1.2)分钟,8小时能够接诊48位患者,实际接诊145位患者,超出2倍多.结论 普通门诊首诊和复诊病历合格率较低,加强针对门诊病历书写的继续教育非常重要.需要引起重视的是普通门诊患者流量太大,应当科学合理地制定单位时间内患者流量,确保医疗质量,努力营造医患和谐、共享尊严的医疗环境.
目的 瞭解臨床醫師普通門診首診及複診病歷閤格率,分析不閤格原因,提齣改進建議.方法 收集首都醫科大學附屬北京朝暘醫院心內科2013年7月8日~7月12日門診病歷,每天隨機抽查門診接診醫師書寫的門診首診病歷10份,連續5天共50份,併一對一追蹤其複診病歷.同期計算門診全天接診患者總數及接診醫師人數,併記錄書寫一份閤格普通門診病歷的時間.結果 普通門診首診病歷閤格率44.0%,複診病歷閤格率45.7%.首診病歷不閤格的主要原因為缺項,複診病歷不閤格的主要原因為缺乏對首診治療或診斷的反饋性記錄.連續5天患者的就診人數平均為(812±85)人次/天,接診醫師平均每天接診145例患者,每3.3分鐘接診1例患者.閤格首診病歷和複診病歷的書寫時間分彆為(11.7±1.2)分鐘和(10.7±1.2)分鐘,8小時能夠接診48位患者,實際接診145位患者,超齣2倍多.結論 普通門診首診和複診病歷閤格率較低,加彊針對門診病歷書寫的繼續教育非常重要.需要引起重視的是普通門診患者流量太大,應噹科學閤理地製定單位時間內患者流量,確保醫療質量,努力營造醫患和諧、共享尊嚴的醫療環境.
목적 료해림상의사보통문진수진급복진병력합격솔,분석불합격원인,제출개진건의.방법 수집수도의과대학부속북경조양의원심내과2013년7월8일~7월12일문진병력,매천수궤추사문진접진의사서사적문진수진병력10빈,련속5천공50빈,병일대일추종기복진병력.동기계산문진전천접진환자총수급접진의사인수,병기록서사일빈합격보통문진병력적시간.결과 보통문진수진병력합격솔44.0%,복진병력합격솔45.7%.수진병력불합격적주요원인위결항,복진병력불합격적주요원인위결핍대수진치료혹진단적반궤성기록.련속5천환자적취진인수평균위(812±85)인차/천,접진의사평균매천접진145례환자,매3.3분종접진1례환자.합격수진병력화복진병력적서사시간분별위(11.7±1.2)분종화(10.7±1.2)분종,8소시능구접진48위환자,실제접진145위환자,초출2배다.결론 보통문진수진화복진병력합격솔교저,가강침대문진병역서사적계속교육비상중요.수요인기중시적시보통문진환자류량태대,응당과학합리지제정단위시간내환자류량,학보의료질량,노력영조의환화해、공향존엄적의료배경.
Objective To understand the up-to-standard rate of initial and follow-up medical records among clinicians in general out-patient,and to analyze the unqualified reasons and suggestions for improvement.Methods From July 8,2013 to July 12,2013,collect ten of initial out-patient medical records daily randomly in the Heart Center of Chaoyang Hospital of Capital Medical University,on 5 consecutive days,a total of 50,and one to one track their referral records.Over the same period,calculating the total number of out-patient patients and doctors in the whole day,and recording the time of writing a qualified general out-patient medical record.Results The up-to-standard rate of the first outpatient medical records is 44.0% and the follow-up records is 45.7%,the main reason of the unqualified initial records is missing items,the main reason of the unqualified follow-up records is lack of feedback records about the initial treatment or diagnosis.For 5 days the number of patients with an average of (812± 85) per day,the number of patients' admission by one doctor is 145 on average per day,one patient received 3.3 minutes.The time of writing a qualified initial medical records and follow-up records were respectively(11.7±1.2) minutes and (10.7±1.2) minutes,48 patients should be treated in 8 hours,but the actual admissions is 145,which is 3.02 times of the theory number of admissions.Conclusions The up-to-standard rate of initial and follow-up medical records is low,and it is important to strengthen the continuing medical education about paying full attention to writing medical records; It is worthy to note that the general outpatients flow is too large,we should develop the number of patients per unit time reasonably,to ensure the quality of medical treatment,and create a harmonious relationship between doctors and patients,sharing the dignity of medical environment.