全病歷質(zhì)控檢查總結(jié)

準(zhǔn)認(rèn)(二)、病程記錄：1、首次病程記錄：1)部分病史特點(diǎn)不精練，3)個(gè)別病歷首次病程診斷依據(jù)不充分，個(gè)別病歷缺鑒別診斷。4)遺歷上級(jí)醫(yī)師查房記錄粘貼痕跡明顯，未體現(xiàn)查房醫(yī)師水平。3)部分病錄數(shù)率600%02%400%500600%00021、病歷首頁(yè)存在缺項(xiàng)、漏項(xiàng)，填寫不規(guī)范；少數(shù)病歷字跡潦草，個(gè)別2、主訴與現(xiàn)病史不符；主訴不夠簡(jiǎn)練，現(xiàn)病史描述有缺陷，如缺疾病粘貼過(guò)多，存在重復(fù)粘貼。5、手術(shù)病歷，在記錄方面缺陷比較多，如：術(shù)前小結(jié)中無(wú)術(shù)中、術(shù)后寫不全，重大治療措施(手術(shù))前無(wú)溝通記錄，未交待術(shù)后標(biāo)本去向，個(gè)別超7天病歷45份共超%85.1%數(shù)數(shù)2數(shù)0070科室月份123456789合計(jì)眩暈668985112咳嗽00246889122喘病002023723251650002362523037癌病0000001100001便血病0000000001001外科脾心痛1201114101000100002011004膽脹003443734661便血病0010000000001疝氣0014120432330石淋0012469833452腸癰00013343613226痣000221288312290000010000102生0000011101206尿路感染0000010000001腱鞘囊腫0000000100001腦震蕩0000000010001瘤0000001000001分娩43895534883婦產(chǎn)異味妊娠024220131112科剖宮產(chǎn)499癥瘕病100023310332骨傷骨折120221232124159科弊病1000000100024兒科小兒泄瀉502020012211肺炎喘嗽0012感冒病0003021310010000001000034胎黃0000001000001膝弊病101356524340項(xiàng)弊病(神1078腰腰痛病(腰1392720192018171923520210面神經(jīng)癱13431115412430瘓神經(jīng)性耳0000000000101鳴胸弊0001000000001中風(fēng)0000000200002弊病412000000100017脊柱炎0001000000001合計(jì)42521141381751821621771942092142671926科一聯(lián)二聯(lián)三聯(lián)3(0.6%)0(0%)0(0%)110(50.2%)5(2.3%)0(0%)495(58.5%)47(5.6%)4(0.4%)1009(79.4%)220(17.3%)0(0%)593(52.5%)191(17%)0(