| 摘要: |
| 目的 通过分析住院病历质量缺陷的分布情况，制定相应的改进措施，从而不断提高医疗质量。方法 随机抽取住院病历1 862份，组织4名专家审查病历质量存在的主要问题，分析产生的原因。结果 共发生落实制度方面的缺陷110例次，诊疗质量缺陷198例次，病历书写质量缺陷3 106例次。结论 医院在质量管理方面做得还不够到位，内涵质量有待提高，应通过加强教育培训，强化各环节质量控制和建立科学评价机制，提升医疗质量管理水平。 |
| 关键词: 住院病历 医疗质量 医疗缺陷 分析 |
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| Analysis of the Quality Defect from Inpatient Medical Records in a Hospital |
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| Abstract: |
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Objective
To identify appropriate countermeasures，so as to raise the medical quality through analysis of medical quality defects distribution. Methods 1 862 cases of in-patients were randomized for the investigation. 4 experts are organized to review the quality of medical records to analyze the main problems and its causes. Result There are 110 defects in implementing system，198 defects in diagnosis and treatment quality，3 106 defects in the writing quality of medical records. Conclusion Hospital quality management has not done enough in place，and content quality to be improved. In order to elevate the medical quality，it is suggested to train doctors in the medical record，enhance quality control in every medical procedure，and establish a scientific doctor estimation system. |
| Key words: medical record,medical quality,medical defect,analysis |
