CAJ | 학술논문

目的：针对性对出院记录书写存在的缺陷问题进行分析，寻找改进对策。方法依据原卫生部颁布的《病历书写基本规范（2010年版）》与军区卫生部《病案质量检查评分细则》，对某医院2012年6月1日至2014年5月31日出院归档前的终末病案9936份，针对病案中出院记录质量进行质控检查统计，共检出出院记录存在缺陷936份（占9.43%），将出院记录按照患者一般信息、入院基本情况、诊疗经过、主要辅助检查结果、病理诊断、出院情况、出院主要诊断、出院医嘱、医师签名等内容，逐项质控检查进行分析统计。结果936份出院记录存在质量缺陷，按出院记录存在缺陷项目统计依次为重要辅助检查结果漏记109份（占11.66%）；诊疗经过不具体106份（11.35%）；出院医嘱内容不全103份（11.07%）等16项。结论加强临床医师岗前培训、强化法律意识与责任心、加强临床基本素养的历练、落实三级医师负责制、奖惩并举激发质量意识等措施，对提高病案质量管理与病历书写质量具有重要意义。
목적：침대성대출원기록서사존재적결함문제진행분석，심조개진대책。방법의거원위생부반포적《병역서사기본규범（2010년판）》여군구위생부《병안질량검사평분세칙》，대모의원2012년6월1일지2014년5월31일출원귀당전적종말병안9936빈，침대병안중출원기록질량진행질공검사통계，공검출출원기록존재결함936빈（점9.43%），장출원기록안조환자일반신식、입원기본정황、진료경과、주요보조검사결과、병리진단、출원정황、출원주요진단、출원의촉、의사첨명등내용，축항질공검사진행분석통계。결과936빈출원기록존재질량결함，안출원기록존재결함항목통계의차위중요보조검사결과루기109빈（점11.66%）；진료경과불구체106빈（11.35%）；출원의촉내용불전103빈（11.07%）등16항。결론가강림상의사강전배훈、강화법률의식여책임심、가강림상기본소양적력련、락실삼급의사부책제、장징병거격발질량의식등조시，대제고병안질량관리여병역서사질량구유중요의의。
Objective To analyze the defects in discharge records, and find improvement measures.Methods Checking 9936 copies of terminal medical records from June 1st, 2012 to May 31, 2014 based on the former Ministry of Health issued the "medical writing basic specification(2010 edition)" and the Military Health Department "record quality checks scoring rules". There are 936 discharge records existing flaw, accounted for 9.43%. Results Checking and analyzing patients basic information, Basic situation in hospital, Diagnosis and treatment, the main ancillary diagnostic test results, the pathological diagnosis, discharge conditions, the main discharge diagnosis, doctor's advice, physician signature, etc. 936 discharge records exist quality defects. The Defect project statistics were, in order, important ancillary diagnostic results omission 109(11.66%); no specific Diagnosis and treatment 106(11.35%); Discharge Instructions content incomplete 103(11.07%) and other 16 items. Conclusion The methods of strengthen pre-service training, strengthen legal awareness and sense of responsibility, strengthen basic knowledge of clinical experience, the physician in charge of the implementation of three system, incentives and other measures to stimulate the sense of quality have important significances for improving the quality of medical record management and medical record writing quality.