儿科住院病历质量缺陷分析

摘要

Objective:To improve the quality of medical records of pediatric inpatients and to guarantee the records' accuracy and safety. Method:The quality control data of 1059 medical records of pediatric inpatients in our hospital from October 2011 to June 2013 were statistically analyzed,the quality defects of the medical records were divided into two categories:standard regulatory defects and content quality defects. Summarized and analyzed the apparent quality defects of medical records. Result:The quality control results of 1059 pediatric medical records indicated content quality defects, these results were compared with standard regulatory defects,statistical significance was revealed(P<0.01). Conclusion:Pediatric medical records are adequate to the requirements for Hasic Norms of Medical Records according to format specification and regulation,but the level of content quality does not improve accordingly. To achieve continuous improvement of medical record quality,we still have to strengthen quality management measures.%目的：进一步提高儿科住院病历书写质量，保障儿科诊疗质量与安全。方法：统计分析2011年10月-2013年6月本院共计1059份儿科住院病历的质控资料；将病历质量缺陷归分为两类：一类为规范规制类缺陷；一类为内涵质量缺陷；总结并分析病历中凸显的质量缺陷问题，结果：1059份儿科住院病历质控结果凸显病历内涵质量缺陷，与规范规制缺陷比较有统计学意义（P<0.01）。结论：儿科病历书写在格式规范、规制上很快符合《病历书写基本规范》要求，但内涵质量并不同步提高；实现儿科病历质量持续改进，需进一步加强质量管理措施。