手术切口分类和愈合等级选择的相关探讨

摘要

Objectives To accurately select the classification and grade of healing and improve the quality of statistical data.Methods Two patients discharged from hospital 2011-2012 information of operation patients were screened out through the review of surgical incision healing grade classification and inaccurate statistics of medical records,medical records are not sterile surgical cases fill for aseptic operation.Results It is showed that the error rate in 2012 was significantly less than in the year of 2011.Conclusion It is helpful to improve the quality of medical records by establishing a unified classification and grading criteria.%目的 准确选择手术分类及愈合等级,提升统计报表数据质量.方法 选取医院2011~2012两年的出院患者信息,对进行手术操作的患者进行筛选,通过审查找出手术切口分类及愈合等级不准确的病案,统计出不属于无菌手术的病历填写为无菌手术的例数.结果 发现2012年误记率明显小于2011年.结论 制定统一的手术分类及愈合等级标准有助于提升病案质量,规范化培训可以让统计数据更可靠.