目的 对2015年7月1日至2016年6月30日的1497份终末出院病案的书写质量进行统计分析,查找其缺陷问题,并提出相应解决方案.方法 依据原卫生部颁布的《病历书写基本规范》及住院病案质量评价用表设计病案质控量表,对病案缺陷项目进行分类统计与分析.结果 1497份病案中有1494份存在不同程度的缺陷,缺陷率为99.80%.缺陷项数从1处到27处不等,其中3处及以上缺陷有1348份.问题病案比率最高的是临床技术类的中医技术占74.42%,其次是书写规范类的其他书写规范占62.66%,书写规范类的中医内容缺陷病案占52.97%,排第三位.结论 病案质量控制是一个持续管理改进的过程,医院应适度改变中医整体观念思路,实施临床路径管理,实现病案质量控制流程化,引用先进的管理理念与方法,建立一套合理的、科学的,结合自身特点"量身定制"的质量管理体系.%Objective A statistical analysis of the writing quality of 1497 discharged cases from July 1, 2015 to June 30, 2016 was carried out to find out the defects and the corresponding solutions. Methods According to the Ministry of Health promulgated the "medical records to write the basic norms"on the medical records of defective items classified description. Results There are 1494 of 1497 cases of varying degrees of defects, the defect rate was 99.80%. The number of defects ranges from 1 to 27, of which 3 and above have 1348 defects. The highest proportion of the problem is the clinical technology of traditional Chinese medicine technology (74.42%), followed by other norms of writing norms (62.66%), Writing norms of traditional Chinese medicine content defects accounted for 52.97% of cases, ranked third. Conclusion Quality control of medical records is a process of continuous management improvement. Hospital should be appropriate to change the overall concept of traditional Chinese medicine thinking, implement clinical path management and to achieve the quality of disease control process, as well as the application of advanced management concepts and methods, establishing a "made to measure" quality management system which is reasonable, scientific and with its own characteristics.
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