【摘要】 目的为规范出院记录书写、提高病案质量,对出院记录进行专项检查,找出问题分析,寻找改进措施。方法依据原卫生部颁发的《病历书写基本规范(2010版)》,结合江苏省卫生厅对出院记录的要求,自设检查表,将缺陷分为15项,对2014年5月某院归档的555份病历进行出院记录质量的专项检查。结果在此次专项检查中缺陷项在前3位的分别是带药疗程缺失76.92%,主要诊疗经过过简或缺失58.56%,门诊随访及注意事项缺失54.95%。结论从格式、标准和系统设置上强化管理,是进一步提高出院记录书写质量的新方法。更多还原

【Abstract】 Objective In order to regulate the discharge records and improve the quality of medical records,conduct special inspection, analyze the defects, find improve countermeasures. Methods According to relevant provisions of medical record writing fundamental rules issued by the ministry of health in 2010, creating our own survey and dividing the defects into 15 indexes, taking a special inspection to the quality of 555 discharge records combined with rules of the Jiangsu Province health department. Results In the special inspection, the top 3 of defects was drug treatment 76.92%, main diagnosis and treatment 58.56%, outpatient follow-up and the matters needing attention 54.95%. Conclusion Strengthen management from the formats, standards and system settings,which is a new method to further improve the quality of discharge records.更多还原