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目的调查某地区医务人员书写住院病历的缺陷和影响书写积极性的因素,总结提升病历书写积极性的措施。方法对某地区三所医院2014年全年的病历进行审查及对影响医务人员书写病历积极性因素进行调查。结果某地区三所医院全年病历共出现2800份缺陷病历,病历主要缺陷类型为病历首页患者基本信息不完整,占比10.9%;医生病历书写积极性造成影响的因素主要为思想因素,未能认识到病历书写的重要性,占比52.3%。结论优化病历管理机制,调动医生病历书写积极性,提升医院病历书写质量,有助于防止医患矛盾的发生。
Objective To investigate the shortcomings of hospital medical records written by medical personnel in a certain area and the factors that influence the enthusiasm of writing, and summarize the measures to enhance the writing enthusiasm of medical record. Methods The medical records of the three hospitals in a certain region in 2014 were reviewed and the factors influencing the enthusiasm of medical staff to write medical records were investigated. Results A total of 2,800 cases of medical records were found in the three hospitals in a certain region. The main defects of the medical records were incomplete information on the first page of the medical records, accounting for 10.9% of the total. Medical doctors’ writing enthusiasm was influenced mainly by ideological factors and failure to recognize The importance of writing medical records, accounting for 52.3%. Conclusion Optimizing the medical record management mechanism, mobilizing the enthusiasm of medical records writing, and improving the writing quality of medical records help to prevent the contradiction between doctors and patients.