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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 existing in writing and writing of obstetric medical records of a hospital, analyze the causes and make countermeasures. Methods A retrospective analysis was made on the quality of 2303 records of obstetric discharge in a hospital in 2007 and statistical analysis of the defects. Results A total of 1417 medical records were found to be defective, accounting for 61.5% of the total number of medical records, totally 1527. Conclusion It is one of the countermeasures to strengthen the training of resident medical record writing, hold special lectures and improve the legal awareness of medical staff to ensure the quality of medical record writing.