| 摘要: |
| 目的 探讨通过加强卫生监督推进医疗机构提高医疗安全质量。方法 抽取上海市长宁区内二甲以上综合医院运转病历，从住院病历基本书写项目，有创操作记录、特殊检查、特殊治疗、病危（重）等告知，手术病历相关内容，医疗安全相关制度执行情况等4个方面进行督查评估。结果 抽查病历124份，手术病历涉及普外科等4个专业；涵盖“有创操作、特殊检查、特殊治疗、病危（重）告知”等项目的病历涉及心内科等5个专业，均存在问题。结论 对易发生问题的专业进行广覆盖、常态化的医疗安全监管是促使医疗机构提高医疗质量的有效手段。 |
| 关键词: 医疗质量 医疗安全 卫生监督 病史督查 |
| DOI： |
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| 基金项目: |
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| Analysis of Patient Safety Quality in Medical History Inspection |
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| Abstract: |
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0bjective
To enhance health supervision to improve medical quality in medical institutions.Methods Drawing out in-patient department case history in 2A comprehensive hospitals and above，we inspect and evaluate it from 4 aspects，including basic writing，invasive treatment，specific examination and treatment，execution system，and so on.Results Total 124 cases being drawn out have problems.Surgical operation case history comes from 4 departments for example general surgery etc.Other cases include basic writing，invasive treatment，specific examination and treatment，execution system come from 5 department for example cardiologie department etc.Conclusion It is an effective measure that extensive and normalized patient safety inspection on the departments that frequently goes wrong for improving medical quality，regulating medical service，and decreasing medical negligence and tangle. |
| Key words: medical quality,patient safety,health supervision,medical history inspection |
