【摘要】 目的探讨我院病案存在的主要问题,分析原因,制定对策。方法对我院2009年上半年抽查的840份病案存在的缺陷进行统计分析。结果缺陷最多的是病程记录占37.17%。其次是入院记录占25.67%,病案首页18.18%,出院记录5.35%等。结论加强质量教育和管理力度,减少病历缺陷,提高病案质量。更多还原

【Abstract】 Objective To investigate the dominate problems present in medical records in our hospital and analyze reasons in order to develop countermeasures. Methods Statistical analysis was done on defects of 840 copies of medical records randomly inspected in the first half of 2009. Results Defects mainly lied in progress note,accounting for 37.17%,followed by resident admit note and first page of medical records,accounting for 25.67% and 18.18%,respectively. Discharged note accounted for 5.35%,etc. Conclusion Quality education and management intensity should be enhanced to reduce defects and improve the quality of medical record.更多还原