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目的完善院前病案质量标准,明确病案质量管理目标,促进院前急救质量提高。方法回顾性分析2009年1月1日到12月31日的病案质量,共6,453份,总结病案中的缺点或缺陷。结果急救病案中有缺陷病案1,355份,缺陷率为23.6%,病案总体质量令人满意,但缺点和陋习仍然存在。结论病案管理工作中,要文字质量与内涵质量并重;病案质量控制小组应切实履行好职责,完善管理制度,加强培训,提高院前急救病案质量和院前急救质量。
Objective To improve the quality standards of pre-hospital medical records, clarify the objectives of medical records quality management and promote the improvement of quality of pre-hospital emergency services. Methods The quality of medical records from January 1 to December 31, 2009, was retrospectively reviewed. A total of 6,453 medical records were collected to summarize the shortcomings or defects in the medical records. Results There were 1,355 defective cases in the first aid case, with a defect rate of 23.6%. The overall quality of the case was satisfactory, but the shortcomings and bad habits still existed. Conclusion In the work of medical record management, both the quality of words and the quality of connotation should be equalized. The quality control team of medical records should effectively perform its duties, improve the management system, strengthen training and improve the quality of first-aid medical records and the quality of pre-hospital emergency care.