147份死亡病案质量调查分析.DOCVIP

147份死亡病案质量调查分析 李立芹岳学敏张宏亮杨士杰赵俊秀 冀中能源邢台矿业集团总医院质控办 摘要： 目的分析死亡病案存在的缺陷原因，以制定相砬的防范措施，提高死亡病案书 写质量。方法采用冋顾性死亡病案质量调查法，对某院2014年3月-2017年3 月的147份死亡病案进行质量调查，并对发现的缺陷及原因进行分析。结果死 亡病案存在的主要缺陷有死亡病例讨论发言雷同、未认真分析死因和未总结经验 教训，占26. 79%;抢救记录中对生命体征变化、用药及其他抢救措施的描述不具 体、错记或漏记，占22. 62%;死亡记录中死亡时间与抢救记录、医嘱单、体温单 不一致，占17. 26%;病案首页主要诊断选择错误，占13.10%。结论死亡病案质 量仍存在一定问题，可以通过增强医师的法律意识，严格执行死亡病例讨论制 度，加强主要诊断选择的培训，加大质控力度，完善电子病历系统等措施提高 死亡病案书写质量。 关键词： 死亡病案;质景;分析; 收稿日期：2017-07-04 A Quality Investigation Analysis on 147 Cases of Death Medical Records Li Liqin Yue Xuemin Zhang Hongliang Yang Shijie Zhao Junxiu Department of Quality Control, Ji Zhong Energy Xing Tai Mining Group General Hospital; Abstract： Objectives To analyze the causes of the defects in death cases, develop corresponding preventive measures to improve the quality of writing of death cases. Methods A retrospective death case quality investigation was used to conduct quality investigation of 147 deaths from the hospital from March 2014 to March 2017, and analyzed the defects and causes. Results The main defects in the death cases were the discussion of the death case and the unserious analysis of the cause of death and the unlearned lessons, accounting for 26.79%. The description of vital signs， drugs and other rescue measures in the salvage record is not specific, error recording or omission，accounting for 22. 62%; The death time in the death note was not consistent with the rescue record, medical order and temperature sheet, accounting for 17. 26%. The main diagnostic error of the main diagnosis was 13.10%. Conclusions There were still some problems existing in Death medical record quality, we could improve the writing quality of death medical records through enhancing the legal consciousness of physicians, strictly implementing the system of death case discussion, strengthening the training and selection of diagnostic intensify quality control, perfecting the electronic medical record system and other measures. Keyword： Death medical records; Qualit