摘要
目的探讨某医院产科病案病程记录书写存在的主要问题,分析原因,制定对策。方法回顾性分析2007年某医院产科出院病案2303份病程记录书写质量,并对缺陷进行统计剖析。结果检查病案中共有1417份病程记录存在缺陷,占病案数的61.5%,共1527项。结论加强住院医师病历书写的培训,举行专题讲座,提高医务人员法律意识是保证病历书写质量的对策之一。
Objective To explore the main problems in obstetric medical records writing and make the corresponding countermeasures. Methods Qualities of 2303 medical records of obstetric patients discharged in 2007 were analyzed retrospectively. Results 1527 defects were found in 1417 medi- cal records, accounted for 61.5% of the total records. Conduslon It is one of the strategies for ensuring the quality of medical records writing, to im- prove health professionals＇ awareness towards law, strengthen the training of residents and hold seminar on medical records writing.
出处
《中国病案》
2010年第2期14-16,共3页
Chinese Medical Record
关键词
产科病历
病程记录
obstetric medical records
medical records
