CAJ | 학술논문

目的：调查某地区医务人员书写住院病历的缺陷和影响书写积极性的因素，总结提升病历书写积极性的措施。方法对某地区三所医院2014年全年的病历进行审查及对影响医务人员书写病历积极性因素进行调查。结果某地区三所医院全年病历共出现2800份缺陷病历，病历主要缺陷类型为病历首页患者基本信息不完整，占比10.9%；医生病历书写积极性造成影响的因素主要为思想因素，未能认识到病历书写的重要性，占比52.3%。结论优化病历管理机制，调动医生病历书写积极性，提升医院病历书写质量，有助于防止医患矛盾的发生。
목적：조사모지구의무인원서사주원병력적결함화영향서사적겁성적인소，총결제승병역서사적겁성적조시。방법대모지구삼소의원2014년전년적병력진행심사급대영향의무인원서사병력적겁성인소진행조사。결과모지구삼소의원전년병력공출현2800빈결함병력，병력주요결함류형위병력수혈환자기본신식불완정，점비10.9%；의생병역서사적겁성조성영향적인소주요위사상인소，미능인식도병역서사적중요성，점비52.3%。결론우화병력관리궤제，조동의생병역서사적겁성，제승의원병역서사질량，유조우방지의환모순적발생。
Objective To investigate the defects existing in the hospitalized medical records of the medical staff as well as the factors influenced the enthusiasm of medical records writing in Sanshui district, and summarize the positive measures to improve the enthusiasm of medical records writing. Methods To conduct an investigation of all the medical records of three hospitals in Sanshui district in 2014 as well as perform a survey on the enthusiasm factors of medical records writing of the medical staff. Results There were 2800 cases of defect medical records in the three hospitals with the district during the whole year. The main defect type was the incomplete basic information of the patients, which accounted for 10.9%. The main influencial factor that affected the medical records writing of the doctors was ideological factor, they could not realize the importance of medical records writing, which accounted for 52.3%. Conclusions It is helpful for preventing the occurrence of medical disputes through optimizing the management mechanism, mobilizing the enthusiasm of doctors and improving the writing quality of medical records.