产科病案出院记录存在问题分析及改进措施
张秀美;李泉芳;张桂芳
【期刊名称】《中国病案》 【年(卷),期】2016(017)009
【摘要】Objective To improve the writing quality of obstetrical medical records. Methods 300 obstetrical discharge records were selected randomly in April 2016,then took a special inspection on the quality according to the standards and taking the results in the excel doing analysis. Results There were 281 records existing defects,the defect rate was 93.7%,in which the most common defects was 246 items of discharged situation,which accounted for 82%. The major problem was writing incompletely,no newborn's record or newborn's record disagree with the fact. Conclusions We could improve the writing quality of discharged records by a number of measures combined with the features of obstetrical specialty.%目的：提高产科病案出院记录书写质量。方法随机抽取某院2016年4月份300份产科出院病案，按照评价标准进行专项质控，将质控结果录入 Excel 表中进行统计分析。结果300份产科病案中281份存在缺陷，缺陷率93.7%，其中最常见的缺陷为出院情况项目，有246份，占82%，主要表现为记录内容不全，无新生儿情况记录或新生儿情况与实际不符。结论产科出院记录存在缺陷，应结合产科专业特点，多措并举，提高出院记录书写质量。 【总页数】3页(27-29)
产科病案出院记录存在问题分析及改进措施
