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目的:对内科住院患者病案书写质量状况进行总结分析,找出其中的问题,并提出相应的对策建议。方法:对浙江省舟山市第二人民医院2015年7~8月内科住院患者的病案书写质量,进行分析总结,从主诉情况、病史情况、体检情况、病程登记情况以及诊断情况等进行分项分析。从中找出病案书写过程中存在的质量问题。并根据质量问题,提出改进措施和建议。结果:研究发现在所有病历中,有92份为甲级病历,有56例为乙级病历,有2份为丙级病历。结论:加强对业务能力的学习和培训,提高质量意识,做好对病案书写的监督和检查,是有效避免病案书写质量问题的有效手段。
OBJECTIVE: To summarize and analyze the medical records quality of medical inpatients, find out the problems and put forward corresponding countermeasures and suggestions. Methods: The quality of medical records of inpatients from July to August 2015 in Second People’s Hospital of Zhoushan City, Zhejiang Province was analyzed and summarized. According to the main complaint, medical history, physical examination, registration of disease course and diagnosis, . From which to find out the quality of the medical record writing process. And according to the quality problem, put forward the improvement measure and the suggestion. RESULTS: The study found that 92 of the medical records were Grade A medical records, 56 were Grade B medical records and 2 were Grade C medical records. Conclusion: Strengthening the study and training of operational abilities, raising the awareness of quality and supervising and examining medical records writing are effective measures to effectively prevent the quality of medical records writing.