【摘要】 目的通过分析辅诊检查申请单书写缺陷状况进行分析并提出对策,为医院质量管理及医疗安全提供参考。方法通过抽检某院2014年1月-9月临床医师书写的辅诊检查申请单11369份,质控中发现存在质量缺陷。结果辅诊检查申请单存在质量缺陷者829份,不合格率为7.29%。结论辅诊检查申请单书写是否完善、规范,直接关系着辅诊诊断报告的及时性、准确性及病案资料的完整性。强化临床医师法律意识与责任心是提高医疗文书书写质量的有效途径。更多还原

【Abstract】 Objective To analyze the writing defects existing in check requisitions and put forward relevant measures. and provide reference for the hospital quality management and medical safety. Methods To conduct a random inspection on the 11369 copies of check requisitions written by clinicians in a hospital from January to September in 2014. and defects were found in the process of quality control. Results There were quality defects existing in 829 copies of check requisitions. and the failure rate was 7.29%. Conclusions The completed and standardized check requisitions were directly related to the timeliness. accuracy and the integrity of medical records materials. To strengthen the legal awareness and sense of responsibility of clinicians is an effective way to improve the writing quality of medical instruments.更多还原