院前急救病历质量管控与改进策略

Quality Management and Improvement Strategy of Pre-Hospital Emergency Medical Records

摘要: 目的：检查院前急救病案质量，列出其中存在的问题，总结归纳，经验分享，以体现院前急救医生的职业价值，提高院前急救质量。方法：检查本中心直属分站2016年全年院前急救病历19,306份，对其内容进行汇总分析。结果: 所检院前急救病历存在急救时间链无逻辑性等10个方面的问题。结论：院前急救病历不只是简单的出诊记录，而是基本的医疗文书，也是法律文书，应遵循准确详实，完整精炼且重点突出的原则，以科学严谨的态度认真书写每一份院前急救病历。

Abstract: Objective: Check the quality of pre-hospital emergency medical records, list the problems, sum up, share experience to reflect the professional value of pre-hospital emergency physicians, and improve the quality of pre-hospital emergency. Methods: We started examining the first emergency medical records of the center in 19306 in 2016, analyzing and summarizing its contents. Results: We found that there are 10 aspects of problems like first-aid time chain without logic in pre-hos- pital emergency medical records. Conclusion: The pre-hospital emergency medical records are not only a simple medical record, but the basic medical documents, and also the legal documents. So we must follow the principle of accurate and detailed, complete refining and focused, and carefully write each pre-hospital emergency medical record.