1. Question: 1. There is a phenomenon that the signature of the superior doctor is not timely. 2. The discussion of some difficult cases lacks the content of traditional Chinese medicine. 3. The medical history of some cases is not comprehensive, and there is a phenomenon of missed diagnosis. 4. Some medical records are not strictly audited after copying. 5. Doctors don't collect medical history carefully. For example, the admission record "no history of drug allergy" is inconsistent with the actual situation of the patient. II. Rectification measures: 1. Cultivate good habits, pay attention to details, have a rigorous work attitude, and strengthen the construction of work style. 2. Pay attention to internal control. The director should play his due role and discuss the contents of traditional Chinese medicine in difficult cases in time. 3. Standardized training and assessment of medical record writing for clinicians. Strengthen the training of medical personnel, adhere to the quality inspection of medical records, hold regular exhibitions and reviews of medical records, and doctors and nurses at all levels should conduct self-examination of their medical records, and the quality control of medical records should be linked to the personal evaluation of doctors. On April 5th, 20 1X, 752 Japanese quarterly medical records were randomly selected for quality control. The rate of first-class medical records is 96.7%, the rate of second-class medical records is 3.3%, and there is no third-class medical records. 1. Question: 1. Some running medical records were not printed in time. 2. Home page: Some items are unknown, such as ID card, address and incomplete discharge diagnosis. 3. Discharge record: the content of diagnosis and treatment is simple; The discharge doctor's advice is unknown; Patients who need follow-up have no follow-up period. 4. The implementation of clinical pathway is not in place. 5. Failing to write medical records according to the prescribed content and format. II. Rectification measures: 1. All clinical departments should attach great importance to it, the director of the department should be strict, and the quality control doctors and quality control nurses should be strictly controlled. 2. Each department should strengthen the management of clinical pathway and strictly implement it in accordance with relevant regulations. 3. Implement strict requirements and training for clinicians, accept and exercise the thinking method of medical diagnosis, and standardize their treatment procedures. 4. Conduct training on medical record writing norms and related laws and regulations to improve management level. In July, 20 1X 02, the Medical Department of XX City Hospital of Traditional Chinese Medicine randomly sampled 860 medical records in Japan for quality control. The rate of Grade A medical records reached 96.5%, Grade B medical records reached 3.5%, and there was no Grade C medical records. First, there is a problem: 1. In some medical records, patients did not sign the medical history approval in time. 2. The principle, method, prescription and medicine in individual medical records cannot be highly unified. 3. Some doctors can't use Chinese patent medicine accurately. 4. The dominant diseases identified by some undergraduate departments have not yet reached the forefront of receiving and treating diseases. 5. The diagnosis and treatment scheme in medical records cannot be highly unified with the diagnosis and treatment scheme of dominant diseases.
6. Some medical records have incomplete four diagnoses. II. Rectification measures: 1. All clinical departments should attach great importance to it, the director of the department should be strict, and the quality control doctors and quality control nurses should be strictly controlled. 2. All departments should strengthen the training of Chinese medicine knowledge and improve the ability of syndrome differentiation and treatment. 3. Strengthen the management of dominant diseases. 4 improve the quality and professional level of medical staff, organize medical staff to study regularly, encourage them to participate in continuing education, and improve their professional theoretical knowledge. Strengthen the "three basics" training for clinicians, conduct regular assessments, and reward outstanding doctors. XX City Hospital of Traditional Chinese Medicine Medical Department 20 1X years 65438+ 10/0 Part III: Medical record quality inspection and rectification report 1 Li Cuihua, female, 65 years old, 1400802 1 hepatic encephalopathy. On the same day, Dr. Sun Hongyu was immediately asked to sign by hand. Timely rectification in place. 3. A 6-year-old female with lotus fragrance 14007632 virus eruption found that the course of the disease was recorded twice less, so she immediately asked Dr. Sun Hongyu to complete the recording and put it in place on the same day. 4 Xiong Haibo, male, 2 years old, 14008240 Hand, foot and mouth disease examination, the superior doctor did not sign the rounds, and asked Ni Shaoqin to sign immediately. The rectification was in place that day.
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Quality demonstration medical record rectification report-demonstration word version (4 pages)
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Medical record rectification report
Chapter 1: 20 1X Continuous rectification measures for problems existing in medical record quality inspection in the first half of the year.
20 1X has problems in the quality inspection of medical records in the first half of the year.
Continuous rectification measures
20 1X year,1-June, 300 inpatient medical records were randomly selected, with a grade-a rate of 9 1.7%. In order to improve the quality of medical records and ensure medical safety, the hospital medical record management team conducted an inspection on the quality of medical records, and now the inspection results are reported as follows:
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Compared with last year, the quality of medical records has improved, and no major items and obvious alterations have been found. The filing order is also relatively standardized, and there are not many points deducted for the course record and the time limit for the superior doctor's rounds. However, there are still many problems, especially the surgical records, as follows:
1, the handwriting of medical records is common and illegible, and some medical records have been altered;
2. There are omissions in the first page and eyebrow column of medical records, and the age is not in the unit;
3. The signing of informed consent is not standardized;
4. The content of the current medical history record in the medical record is simple, the diagnosis basis is insufficient, and the chief complaint is inconsistent with the diagnosis and current medical history;
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5. The contents of superior doctors' rounds include supplementary medical history and signs, diagnosis and basis, differential diagnosis and analysis, diagnosis and treatment plan, etc. These are too simple, or too cumbersome, without focus, and do not reflect the true level of superior doctors.
6. Incomplete preoperative preparation records; The first postoperative course record was missing; There are no records on whether the operation went smoothly, intraoperative bleeding, blood transfusion, infusion, urine volume, whether the specimen was sent for inspection, etc. The observation project record is not detailed enough.
Rectification measures:
1. Effectively (from: Wang Dian) raise awareness and attach importance to the quality of medical records.
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2, each department should organize doctors to seriously study and seriously implement the medical record writing standard.
3. All subjects should strengthen exchanges and learn from each other. Organize the study of excellent demonstration medical records, and communicate, study, discuss and consult humbly.
4. The writing of medical documents should be completed in time as required, and the quality supervision of medical records should be further strengthened.
5, medical record quality and quality control rewards and punishments. For poor quality medical records, the hospital will give informed criticism and order him to rectify unqualified medical records within a time limit; Medical records with good writing quality will be commended.