應用出院記錄量表評估某院兒科出院病案書寫質量分析

潘秋莎　顏世軍　孫雨

摘 要：目的 探討提高臨床醫師出院記錄書寫質量的對策。方法 應用出院記錄評分量表，對某院兒科醫師在住院醫師期間的出院病案進行量化評估，按照評價標準進行專項定量質控，將質控結果錄入Excel表中進行統計分析。結果 按照出院記錄評分量表分別對6名兒科醫師擔任第1～5年住院醫師期間，每人每年各20份共600份出院記錄進行評分，采用非參數檢驗對不同年資住院醫師出院記錄總分統計分析，除第4年組與第5年組差異無統計學意義（P>0.01）；其余各組間的平均軼的差異有統計學意義（P<0.01）。出院記錄評分量表中16項書寫內容逐項評分，專項均值低于3分的書寫內容項目集中在：治療經過、病情演變、住院期間用藥及治療期間藥物更換說明。結論 出院記錄量表為臨床醫師規范書寫出院記錄提供了參考標準，不同年資住院醫師的出院記錄書寫質量均需亟待提高。

關鍵詞：出院記錄；書寫；量化評分法

中圖分類號：R197.323 文獻標識碼：B DOI：10.3969/j.issn.1006-1959.2018.22.005

文章編號：1006-1959（2018）22-0014-03

Application of Discharge Records Scale to Assess the Quality of Written Records of Pediatric Discharge in A Hospital

PAN Qiu-sha，YAN Shi-jun，SUN Yu

（Department of Pediatrics，the No.81 Hospital of the PLA，Nanjing 210002，Jiangsu，China）

Abstract：Objective To improve the writing quality of the pediatric discharge summaries. Methods The discharge records of pediatricians in a hospital were evaluated quantitatively by using the discharge summary quality assessment tool. The quality control was carried out according to the evaluation standard， and the quality control results were recorded into the Excel table for statistical analysis. Results According to the report of the discharged records， 6 pediatricians were rated as the 1th to 5th year resident， each 20 total of 600 discharge records per person per year， and the statistical analysis of the total score of the discharged records of different years of residency was performed by nonparametric test， the 4th and 5th year group was no statistically significant difference （P>0.01），the difference in average anecdotes was statistically significant （P<0.01）. The contents of 16 items in the discharge record assessment form were graded， and the items with a specific average of less than 3 were focused on： treatment， progression， medication during hospitalization， and drug replacement instructions during treatment. Conclusion The discharge summary quality assessment tool provides a reference standard for clinicians to write discharge. The quality of discharge records of residents with different seniority needs to be improved.

Key words：Discharge records；Writing；Quantitative scoring method

出院記錄是對患者住院期間診療情況的全面總結，是醫患溝通的橋梁，也是臨床醫師書寫病案技能的集中體現。一份有效的出院記錄，需要簡明扼要準確反映患者住院期間的醫療信息，為患者后續診療提供有效的參考。目前，臨床醫師出院記錄的書寫主要由各科住院醫師、實習醫師在上級醫師的審批下完成。由于缺乏出院記錄書寫質量管理的系統性培訓，書寫技巧主要來自于上級醫師言傳身教以及臨床工作中的自我摸索。如何提高出院記錄書寫質量，減少因出院記錄書寫不規范而造成的不良事件，是每個臨床醫師在醫療實踐工作中亟需解決的問題[1]。目前我國尚無出院記錄書寫的相關指南或建議，國內相關文獻對出院記錄的評估，也只是定性的統計分析，缺乏定量的有效評估資料。2……