【摘要】 依据病历质量评分标准,对2 035份缺陷病历进行分析。病历质量缺陷发生率为13.78%。质量意识淡薄,书写不及时,复制及漏缺项严重等是病历质量缺陷的主要原因。提出端正态度,提高医师自觉意识;分类培训,强化病历内涵质量要求;加强监管,健全分层管理联动机制;定期评比,奖优罚劣等对策建议。更多还原

【Abstract】 According to the medical record quality criteria,2 035 medical records with defects were analyzed. The quality defect rate of medical records was 13. 78%. The low quality consciousness,not timely writing,replication and lack of serious leakage were major causes of medical record quality defects. The paper pointed out that measures need to be carried out including attitude correction,consciousness improvement; classified training,strengthening the connotation of the medical record quality requirements; strengthening supervision and improvement of the layered management linkage mechanism; regular appraisal with bonus and forfeit.更多还原