□ 沈占英 SHEN Zhan-ying 刑时通 XING Shi-tong 何守玉 HE Shou-yu

Objective To understand the current situation of medical records quality in the public hospital, and to explore countermeasures for improving medical records quality. Methods A total of 1825 medical records from April 2018 to April 2020 in inpatient department of the hospital were selected. The medical records were evaluated according to scoring standard of medical records quality to analyze the defects of medical records and the causes. Results Among the 1825 medical records, there were 1737 (95.18%) grade A and 88 (4.82%) grade B medical records. There were no grade C medical records. There were 527 medical record defects, which were, in descending order of frequency, in progress record, admission record, home page of medical record, medical advice and medical records writing, discharge record, informed consent,auxiliary examination, and in surgery record. In cause analysis of medical record defects, it was found that standardized training for medical records, poor department management and incomplete informatization were more common causes in residents than in attending physicians and those with higher professional titles (p＜0.05). Conclusion The quality of medical records is generally good. However, there are many defects in medical records. It is necessary to strengthen standardized medical record training, legal education, and management and supervision, and to improve information system.

病历是医务人员对患者检查、疾病诊断、疾病治疗过程以及疾病发生、发展、转归的记录，包括文字、影像、图像、病理学结果等资料的总和，既是医务人员临床实践工作总结，也是临床教学、科学研究的重要材料，以及医疗机构质量管理的体现[1]。病历是处理医疗纠纷时法律责任的判断依据，也为患者提供保健档案、医疗保险依据，还是评估医疗服务治疗的方式之一[2-3]。因此，病历质量对医疗机构服务质量、临床教育、科学研究、医院管理等发挥着重要作用，病历质量管理的重要性不言而喻，有效提高住院病历质量已成为医疗机构、社会关注的热点。本文通过选取我院1825份住院病历，分析其存在的质量问题，探讨相应的管理对策，希望为提高住院病历质量提供参考意见。

对象与方法

1.研究对象。从2018年4月-2020年4月我院住院部15368例出院患者病历中随机抽取1825份作为研究对象。

2.研究方法。对随机抽取的1825份住院病历依据《住院病历质量评分标准》进行检查并评分，评分项目包括病案首页(10分)、入院记录(20分)、病程记录(手术病历25分、非手术病历35分)，手术科室相关记录(10分)，上级医师查房记录(10分)、出院记录(10分)、辅助检查(5分)，医嘱及病历书写(10分)。总分≥90分为甲级病历，75分≤总分＜90分为乙级病历，总分≤75分为丙级病历，其中病历评分扣分分值最高不超过该项目总分值。在进行病历质量评分时首先根据单项否决条款进行判定，包括病历首页空白、入院24h内无入院记录、抢救病人无抢救记录、无麻醉记录单、无手术记录、出院患者无出院记录、死亡患者无死亡记录、篡改伪造病历，经上述单项否决条款判定为丙级病历的不再进行质量评估。……