Quarterly analysis of enhanced prevention of medical disputes.docVIP

 PAGE \* MERGEFORMAT 9 Quarterly analysis of enhanced prevention of medical disputes Of: Zhang Tian Jian, Yuan-Yuan Li, Bo, Ren Yu Jiang [Keywords:] medical history; management; prevention; medical disputes To enhance the quality of the process control of forces, we follow the lt;lt;healthcare system management specificationgt;gt; the quality of medical records for quarter, proved that regular quality checks cases, enabling hospitals to prevent medical disputes, is to our hospital in July 2009 ~ September Quality analysis of medical discharge report as follows. A major problem Access to hospital medical records were 4345 copies, of which 386 216 were a problem (time). Mainly: the history of marriage and fertility history and reproductive history is too simple or not the contents of 28, three days before a new course record of consecutive patients admitted to hospital records were incomplete for 19 , hospital records were missing age, lack of unit 12, the first course record and no record of the first ward rounds higher diagnosis and differential diagnosis based on the contents of 13, hospital records of physical examination, heart rate did not complete the 8 copies, after three consecutive days without course record of 1, confirmed the date and the date of the final diagnosis inconsistent 46, Home of the external cause of injury, hospital department and discharge date not filled in 43 cases, three days before admission course no record of three consecutive days of 41, lack of diagnosis, medication, and Efficacy of 37 records, is the lack of a history of major positive symptoms and negative symptoms of the description of the important 28 for the first time the first time, higher medical records and progress notes rounds identical, except for the first time, hospital record, the part of the contents of copy medical records slightly modified after the individual course record of 23 are identical, there are typos 16 medical records, progress notes ar