【摘要】 目的了解三级甲等综合医院外科病历书写存在的问题并实施改进措施。方法根据中国医院协会编写的《三级综合医院评审标准实施指南》中对于住院病历质量的标准,对抽取的400份外科病案进行评价分析,并根据分析结果实施了加大培训力度、及时反馈、完善信息系统网络监控等方面措施。结果改进措施实施后,外科病案缺陷率较改进前明显减少。结论加强外科围手术期运行病历的监管及首页规范填写的专科培训,确实落实病案管理制度等,可提高外科病历书写质量。更多还原

【Abstract】 Objective The paper aims to find out problems existing in the writing of surgical medical records of Grade-A Class-3 general hospital and take improvement measures. Method In accordance with the standards for the quality of hospitalized medical records in the Implementation Guidelines for Review Standards of Class-3 General Hospitals prepared by the Chinese Hospital Association, 400 surgical medical records sampled were evaluated and analyzed, and based on the analysis results, such measures as increase of training efforts, timely feedback, and improvement of network monitoring over information system were taken. Result After the improvement measures were taken, the defect rate of surgical medical records is significantly decreased than before. Conclusion The writing quality of surgical medical records can be improved by strengthening the supervision of running records during the surgical perioperative period, enhancing the specialist training of standard writing of first page, and really implementing medical record management system.更多还原