【摘要】 目的各临床科室病历书写质量影响因素评价;方法依照《住院病历质量评价标准》进行评分,对某一个月全部出院病案普查,统计缺陷;结果甲级病案率95.68%,缺陷总数2352频次;结论提高病历书写质量,要注重医师临床思维的培养和提高上级医师的管理水平。更多还原

【Abstract】 Objective To evaluate factors those influence the quality of medical records of each clinical department.Method According to the Quality Evaluation Criteria of Inpatient Medical Records,we analyzed all the medical records of one month of a hospital.Results Among all the included medical records,95.68% belonged to grade A,and the total number of defects were 2352.Conclusion To improve the quality of medical record,importance should be attached to the training of clinical thinking in physicians as well as the elevation of management skills in senior physicians.更多还原