[1]钟旋卢建军刘秋生.二胎政策下产科病历书写质量分析及管理对策[J].中国卫生质量管理,2017,24(06):34-35.[doi:10.13912/j.cnki.chqm.2017.24.6.12]

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二胎政策下产科病历书写质量分析及管理对策

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第24卷期数: 2017年06期页码: 34-35 栏目: 医疗质量出版日期: 2017-11-28

作者:: 钟旋卢建军刘秋生; 中山大学附属第一医院

关键词:: 二胎政策; 产科; 病历; 质量

Keywords:: Two-Child Policy; Obstetrical Department; Medical Record; Quality

DOI:: 10.13912/j.cnki.chqm.2017.24.6.12

摘要:: 目的比较二胎政策实施前后产科病历书写质量变化情况，探讨二胎政策下提高产科病历书写质量的管理对策。方法收集某院2013年-2016 年产科病历书写质量数据，进行回顾性描述分析。结果二胎政策实施后，该院产科病历书写缺陷率由0.74%提高为0.94%，围手术期记录缺陷与首页缺陷均明显增加。结论医院应把好科室自查关，落实病历环节质控，促进产科病历书写质量和医疗服务质量双提高。

Abstract:: ObjectiveTo compare the writing quality of medical records in the Obstetrics Department before and after the implementation of the two-child policy, and to explore management measures to improve the writing quality of medical records under the two-child policy.MethodsData of the writing quality of medical records in the Obstetrical Department in a hospital from 2013 to 2016 was collected for retrospective descriptive analysis. ResultsAfter the implementation of the two-child policy, the medical records writing defect rate increased from 0.74% to 0.94%, with apparent increase on the writing defect of perioperative record and the home page record.ConclusionHospital should carry out department’s self-inspection, implement link quality control of medical records, promote the improvement of both the writing quality of medical records and the medical service quality in the obstetrics department.

参考文献/References:

［1］唐其江，魏培德，许树根，等.病历质量控制体系运行情况分析［J］.中国病案，2014，15（6）：20-22.

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更新日期/Last Update: 2017-11-28