【摘要】 目的了解病程记录书写缺陷原因,以便有针对性的进行改进。方法依据《陕西省医疗机构临床基础质量考评标准》中《住院病历质量评价表》,对运行病历和终末病历进行质量督查和考评。结果共查阅病历2 113份,病程记录出现缺陷总频次为2 274例次。其中,医嘱变更缺变更理由928例次,占40.81%;重要检查结果缺病程记录866例次,占38.08%;病程记录书写不规范231例次,占10.16%;"记账式"病历,缺少对检查结果的分析及处理意见99例次,占4.35%。结论临床医师应克服懒惰思想,及时书写病程记录;青年医师应加强病历书写技能训练,树立严谨的工作态度;强化带教老师及科主任的责任心;简化医疗文书,精简病程记录,减轻医师负担等。更多还原

【Abstract】 Objective To investigate the reason for defects in record for course of diseases and provide targeted improvements.Method The quality of running and terminal medical records were supervised and evaluated according to the "Medical Records Quality Assessment Form".Result A total of 2113 medical records were investigated;the defects in records for course of diseases were found in 2274 cases.Of them,928 cases lacked of reasons for change of doctor’s orders,accounting for 40.81%;866 cases lacked of course records on important examination results,accounting for 38.08%;231 cases wrote non-standard course records,accounting for 10.16%;book-entry records,which lacked of analysis and suggestions on the test results existed in 99 cases,accounting for 4.35%.Conclusion Clinicians should overcome lazy thinking to real-timely write course records;young physician should strengthen the training of medical writing skills,to develop the rigor of the medical records;the accountability of education teacher and director should be strengthened;medical records should be simplify appropriate to reduce the burden of physicians.更多还原