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目的了解医院感染病案的质量现状,探讨提高医院感染病案质量的方法。方法根据《病历书写基本规范》要求,检查某三甲医院心外科2003~2008年医院感染病案。结果医院感染病案普遍存在书写不完整、不规范问题,其中缺陷率最高的3项内容依次是术前总结(86.8%)、术前讨论(71.7%)和首页诊断(52.8%)。结论从病历形成前、病历形成过程中对医院感染病历书写进行干预,可以切实提高医院感染病案书写质量,为医院感染的管理提供完善的原始资料,促进医院感染的管理。
Objective To understand the status quo of the quality of medical records in hospitals and to explore ways to improve the quality of medical records in hospitals. Methods According to the “basic norms of medical records” requirements, check a top three hospital cardiac surgery 2003 ~ 2008 nosocomial infection. Results There were many incomplete and nonstandard medical records. Among them, the three items with the highest defect rate were preoperative summary (86.8%), preoperative discussion (71.7%) and first page diagnosis (52.8%). Conclusion Intervention before and after the formation of the medical record to hospital infection record writing can effectively improve the quality of the hospital infection record writing and provide the perfect original data for the management of hospital infection and promote the management of nosocomial infection.