CAJ | 학술논문

目的通过统计某三甲医院三年急诊死亡病案数据，分析死亡病案存在的缺陷，提高医院急诊死亡病案质量。方法抽取2012年1月至2014年12月641份急诊死亡病案按照卫生部《病历书写基本规范》和门急诊死亡病历书写质量评分表进行统计分析。结果急诊死亡病案的书写存在死亡原因填写不准确、死亡原因分析不确切（3.28%)；患者死亡时间填写在病案首页、抢救记录、死亡记录、病程记录、医嘱、护理记录前后不一致(0.09%)；死亡抢救记录完成不及时、或无抢救记录（2.18%）；死亡病历讨论记录有内容缺陷（2.65%）；知情同意书缺失、或缺医患签字（1.87%)；有抢救医嘱、无相应抢救记录(1.72%)等缺陷。结论通过加大急诊病案质控力度、加快急诊电子病历软件开发、增加死亡病历环节质控、加强急诊科科室管理，确保提高急诊死亡病案的内涵质量。
목적통과통계모삼갑의원삼년급진사망병안수거，분석사망병안존재적결함，제고의원급진사망병안질량。방법추취2012년1월지2014년12월641빈급진사망병안안조위생부《병역서사기본규범》화문급진사망병역서사질량평분표진행통계분석。결과급진사망병안적서사존재사망원인전사불준학、사망원인분석불학절（3.28%)；환자사망시간전사재병안수혈、창구기록、사망기록、병정기록、의촉、호리기록전후불일치(0.09%)；사망창구기록완성불급시、혹무창구기록（2.18%）；사망병력토론기록유내용결함（2.65%）；지정동의서결실、혹결의환첨자（1.87%)；유창구의촉、무상응창구기록(1.72%)등결함。결론통과가대급진병안질공력도、가쾌급진전자병력연건개발、증가사망병력배절질공、가강급진과과실관리，학보제고급진사망병안적내함질량。
Objectives To collect the data of death medical records in emergency department of a Three A and Tertiary Hospital in three years, analyze the defects existing in them and improve the quality of death medical records in emergency department of the hospital. Methods 641 cases of death medical records in emergency department from January 2012 to December 2014 were selected, and then conduct a statistical analysis according to the"Basic Rules of Medical Records Writing"announced by the ministry of health as well as the quality mark sheet of death medical records in emergency department of our hospital. Results The defects existing in the writing of death medical records in emergency department included inaccurate filling and inexactly analysis of death reason, which accounted for 3.28%, inconformity of death time in home pages, rescue records, death records, progress records, medical advices and nursing records, which accounted for 0.09%, not timely finished or missing death rescue records, which accounted for 2.18%, existing defects in the content of death discussion records, which accounted for 2.65%, the missing of informed consent form or the signatures of doctors and patients, which accounted for 1.87%, some rescue medical advices without relevant records, which accounted for 1.72%. Conclusions We should enhance the quality control of medical records in emergency department, accelerate the development of electronic medical records software, increase the links quality control of death medical records, strengthen the management of emergency department, so as to ensure the improvement of the quality of death medical records in emergency department.