医学信息Issue(38)：103-103,1.
病历外在质量缺陷的分析与改进措施--附966份病历分析
Analysis of Extrinsic Deficiency of Medical Records and the Improving Measures:An Analysis of 966 Medical Records
洪雅君 1张庆云 1龚黛琛1
作者信息
- 1. 厦门市中国人民解放军第174医院，福建 厦门 361003
- 折叠
摘要
Abstract
Objective This paper is to explore the influence of extrinsic defects on final quality control and the improving measures.Methods According to the writing guide line of medical records and the evaluating standard of medical records quality of Nanjing military district,a total of 966 discharge medical records was checked randomly and analyzed,the types and causes were studied and the improving measures were put ed out for ef ectively control ing and raising the external quality of discharge medical records.Results Extrinsic defects of 883 items among 416 medical records were picked out from 966 final medical records which occupied 43%of al randomly checked materials.Thirteen kinds of external defects were outlined.Al the defects were corrected timely.Conclusion Taking active improving measures based on the types and reasons of extrinsic deficiency can eliminate the external defects and promote greatly the quality of medical records.关键词
病历书写规范/外在质量缺陷/病案质量/对策/单项否决Key words
Writing guide line of medical record/Extrinsic defects/Medical records quality/Countermeasures,single item rejection引用本文复制引用
洪雅君,张庆云,龚黛琛..病历外在质量缺陷的分析与改进措施--附966份病历分析[J].医学信息,2014,(38):103-103,1.
