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目的调查手术记录与麻醉记录中手术者姓名填写情况,提高病历书写质量,减少医疗纠纷。方法调取某三级甲等综合医院手术科室2015年4月1日-4月10日出院患者终末病案957份,对手术记录与麻醉记录中手术者姓名填写情况进行专项检查,将存在不一致问题进行统计。结果 957份病案中手术记录与麻醉记录术者姓名填写一致的有890份,占全部的93%。术者及助手姓名填写完全一致的106份,占11.08%;不一致的851份,占88.92%。其中不一致率较高的前5位科室是耳鼻咽喉科(100%)、介入超声科(100%)、泌尿外科(97.44%)、口腔科(97.37%)、普通外科(96.84%)。结论手术记录和麻醉记录中术者姓名一致性较高,但术者及助手姓名完全一致的比例较低,应该增强麻醉医师与手术医师的沟通,合理利用医院电子信息系统,并增强其可操作性,是提高手术记录与麻醉记录中手术者姓名填写一致性的有效方法。
Objective To investigate the names of surgeries in surgical records and anesthesia records, improve the quality of medical record writing and reduce medical disputes. Methods A total of 957 cases of discharged patients’ end-of-life cases from April 1, 2015 to April 10, 2015 were collected from the department of surgery of Grade A general hospital. There will be inconsistencies in carrying out special inspections on the surnames of surgeries and patients in the surgical records and anesthesia records Problem statistics. Results There were 890 surgical records in 957 medical records in accordance with the names of anesthesia recordters, accounting for 93% of the total. Surgeons and assistants to fill in exactly the same name 106, accounting for 11.08%; 851 inconsistent, accounting for 88.92%. The top 5 departments with high inconsistency rates were otolaryngology (100%), interventional ultrasound (100%), urology (97.44%), dentistry (97.37%) and general surgery (96.84%). Conclusion There is a high degree of consistency between the surgeries and anesthesia records, but there is a lower proportion of patients and assistants whose names are exactly the same. The anesthesiologists and surgeons should be better informed, the hospital electronic information system should be rationally used, and their operability should be enhanced Sexual, is to improve the surgical records and anesthesia records in the name of the operator to fill in an effective method of consistency.