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目的通过病历评比与检查,初步了解内蒙古自治区病历质量的现状,总结分析存在的问题,为今后病历质量的控制提供方向。方法对全区25家三级综合医院随机抽取250份病历,其中死亡病历50份,外科乙类以上手术100份,内科疑难危重病历100份。由医疗相关专业专家10人对抽取的十个专业病历质量进行评价,管理专家进行审核。结果甲级病历138份,占55.2%;乙级病历108份,占43.2%;丙级病历4份,占1.6%。结论甲级病历率较低,总体病历书写水平不能令人满意,因此,就存在的质量缺陷进行总结分析,提出整改措施,持续提高全区病历质量。
Objective To understand the current situation of medical record quality in Inner Mongolia Autonomous Region through analyzing and comparing the medical records, summarize the existing problems and provide the direction for the future medical record quality control. Methods A total of 250 medical records were randomly selected from 25 tertiary hospitals in the district, including 50 death records, 100 surgical surgeries of class B and above, and 100 medical critically ill critical medical records. 10 experts from the medical profession evaluated the quality of the ten professional medical records collected and reviewed the management experts. Results Grade A medical record was 138, accounting for 55.2%; Grade B medical record was 108, accounting for 43.2%; Grade C medical record was 4, accounting for 1.6%. Conclusion The grade A medical record rate is low, and the overall medical record writing level is unsatisfactory. Therefore, the existing quality defects are summarized and analyzed, and the corrective measures are put forward to continuously improve the quality of the medical record in the whole district.