眼科病历质量缺陷分析及其防范措施

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Abstract Objective To analyze the reasons of the problems in the medical records writing, find out the solutions, and improve the quality of medical records in the department of ophthalmology, and guarantee the quality and safety of the department of ophthalmology. Methods 347 cases of quality control data in 3271 cases of hospital medical records from 2011 to 2014 were randomly selected; the quality of medical records in the case of defects was analyzed, including the problems and the quality of medical records.Results There were 289 problems in the form of medical record writing and the standard of the medical record, accounting for 83.3% of the defects, and the quality of the content in 58, accounting for 16.7%.Conclusion It is necessary to strengthen quality management measures, improve the legal awareness of medical personnel, and to pay attention to the standard of medical records writing, strengthen supervision, improve the quality of medical records, and to reduce medical disputes.

Key words： department of ophthalmology medical records quality management

Received: 25 July 2015

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R197.323

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	Articles by authors
	SHI Qiong
	ZHANG Hongying
	LV Yuxia
	Li Ailing
	CAO Anxiang
	GAO Min
	HAN Ning

Cite this article:

SHI Qiong,ZHANG Hongying,LV Yuxia等. Analysis of quality defects and preventive measures for electronic medical record in department of ophthalmology[J]. Med. J. Chin. Peop. Armed Poli. Forc., 2016, 27(2): 158-160.

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http://journal08.magtechjournal.com/Jwk_wjyx/EN/ OR http://journal08.magtechjournal.com/Jwk_wjyx/EN/Y2016/V27/I2/158

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