目的 对急诊留观病历中存在的质量问题予以分析,探索提高其书写质量的有效措施,优化管理流程。方法 根据卫生部《病历书写基本规范》、《医疗机构病历管理规定》和《广东省病历书写与管理规范》对2015年6月—12月某院1200份急诊留观病历进行质量检查,对其问题进行汇总分析。结果 发现存在质量缺陷的病历998份,缺陷数4478项,以缺权利义务告知书、授权委托书或填写漏项、出观记录入观情况简单复制、缺验单、病程记录过于简单等缺陷位居前四位,占78.67%。结论 急诊留观病历缺陷突出。临床医师及医院管理者需要就此进行针对性整改,以提高和控制急诊留观病历质量。

Objective To analyze deficiencies of medical records from emergency observation room and explore effective procedures to enhance writing quality of medical records and its management. Methods One thousand two hundred medical records from emergency observation room during June to December 2015 were analyzed according principles of medical records writing,regulations for medical records management in medical institutions by Ministry of Health and regulation for medical records writing and management in Guangdong province. Results 998/1200 medical records were found with deficiency and the total deficiencies were 4478 items. The prominent four types of deficiencies, occupying 78.67%, included absence or incompleteness of the notification of the rights and obligations and power of attorney, simple copy and paste of the medical records, absence of medical test results and too simplicity of the recording of the disease process. Conclusion Prominent deficiencies were found in medical records from emergency observation room. The clinical physicians and hospital administrators should take effective procedures to improve and control the quality of the medical records.