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目的针对死亡病案中存在的缺陷,了解临床医师书写质量存在问题的主要因素并进行分析,使他们认识到病案书写在医疗质量和医疗安全中的重要性。方法对抽取的180份死亡病案质量进行分析。结果 180份死亡病案中出现主要质量缺陷为:主诉与现病史不符的缺陷占31.4%,死亡第一诊断错误的占27.1%,体检与病情不一致的占20%,病程长时间拷贝的占16.3%,死亡讨论过于简单的占8.9%。结论医疗质量是永恒的主题,患者医疗安全是永远的目标,加强对死亡病历的书写质量管理和医师的医德医风教育,正确认识病案做为一种信息载体是极为重要的。
Objective To analyze and analyze the main factors that exist in the writing quality of clinicians and make them realize the importance of medical record writing in the medical quality and medical safety for the defects in death medical records. Methods The quality of the 180 death cases collected was analyzed. Results The main quality defects in the 180 death cases were as follows: 31.4% of the patients complained of the discrepancy between the main complaint and the current illness history, 27.1% of the first diagnosis errors resulting from the death, 20% of the inconsistent medical examination and illness, 16.3% , Death is too simple to discuss 8.9%. Conclusion Medical quality is the eternal theme. The medical safety of patients is the eternal goal. It is very important to strengthen the writing quality management of death records and the medical ethics education of physicians. It is very important to know the medical record as an information carrier correctly.