医学信息
醫學信息
의학신식
Medical Information
2015年
38期
274-275
,共2页
归档病历%质量缺陷%分析%对策
歸檔病歷%質量缺陷%分析%對策
귀당병력%질량결함%분석%대책
Medical record%Quality defects%Analysis%Countermeasures
目的分析归档病历质量缺陷，提出对策，从而提高病历书写质量。方法依据国家卫生部2010版《病历书写基本规范》制定的《归档病历质量评价标准》，随机抽取2014年第四季度3545份归档病历进行评级和缺陷检查。结果甲级病历率95.3%，乙级病历率4.7%，无丙级病历。结论应加大病案质控力度，及时发现问题及时反映，减少病历缺陷，提高病案质量。
目的分析歸檔病歷質量缺陷，提齣對策，從而提高病歷書寫質量。方法依據國傢衛生部2010版《病歷書寫基本規範》製定的《歸檔病歷質量評價標準》，隨機抽取2014年第四季度3545份歸檔病歷進行評級和缺陷檢查。結果甲級病歷率95.3%，乙級病歷率4.7%，無丙級病歷。結論應加大病案質控力度，及時髮現問題及時反映，減少病歷缺陷，提高病案質量。
목적분석귀당병력질량결함，제출대책，종이제고병역서사질량。방법의거국가위생부2010판《병역서사기본규범》제정적《귀당병력질량평개표준》，수궤추취2014년제사계도3545빈귀당병력진행평급화결함검사。결과갑급병력솔95.3%，을급병력솔4.7%，무병급병력。결론응가대병안질공력도，급시발현문제급시반영，감소병력결함，제고병안질량。
Objective To improve the quality of medical records by analyzing the quality defects of medical records and finding countermeasures.Methods According to the national ministry of health, 2010 edition of the medical record writing standard formulated by the medical records quality evaluation standard,to file randomly in the fourth quarter of 2014,3545 medical records of rating and defect inspection.Results The numbers of class A and B respectively were 95.3%and 4.7%,and there was no class C.Conclusion We should strengthen medical record quality control,timely find problems,reduce the medical record defects,improve the quality of medical record.
