7月19日，大江网记者从江西省卫生厅获悉，该厅日前组织了28名专家分5组对江西10家三级甲等、二级甲等医院进行了病历书写质量和病案管理质量督导。督导中发现，一些病历存在内涵质量的缺陷。同时，还存在个别医院门诊医生不写病历，不开正规处方给病人取药等情况。

July 19,，Dajiang network reporter from jiangxi province health department learned，GaiTing has organized 28 experts points on jiangxi 5 groups of 10 three level of first-class、Level 2 of first-class hospital case file writing quality and medical record management quality supervision。Found in the，Some medical records exist of quality defects connotation。At the same time，There are individual outpatient doctors don't write medical record，Don't open the regular prescription for patients get medicine, etc。

　　据了解，此次督导的宜春市人民医院、上饶市人民医院、九江市第一人民医院等10家医院，共查阅病案200份。

According to understand，The supervision of the people's hospital of being、With people's hospital、JiuJiangShi first people's hospital and other 10 hospitals，Access to medical record of 200 copies。

　　督导中发现，这些病历在一定程度上存在着内涵质量的缺陷。例如，主诉不能导出第一诊断，在某医院慢性肾脏疾病主诉为“咳嗽咳痰一月，胸闷气促一周”；现病史不能充分提供诊断与鉴别诊断的依据，如：糖尿病未提及尿量增加、体重下降等情况；诊断不完整、不规范，如：“支肺”、“冠心病”、“心力衰竭”等；鉴别诊断未按照“病史、体检、辅助检查结果”的顺序鉴别；诊疗措施书写模糊、笼统，如：“抗炎”、“制酸”，未写出药名；上级医师查房缺少必要的分析和诊疗意见；邀请会诊的目的不明确；抗生素使用未记录应用指征；术前讨论无针对性，尤其是对可能发生的手术、麻醉意外的防范措施太简单；高风险手术无第二手术方案等。

Found in the，These medical records a certain degree of quality defects exist connotation。For example，Unable to export the first diagnosis complained，In a hospital for complained of chronic kidney disease“Cough sputum January，Chest distress, promote a week”；Now history can't fully provide diagnosis and differential diagnosis，if：Diabetes not mention urine output increased、Weight loss, etc；Diagnosis is not complete、Don't regulate，if：“A lung”、“Coronary heart disease”、“Heart failure”etc；Not according to the differential diagnosis“history、medical、Auxiliary examination results”Order differential；Diagnosis and treatment writing fuzzy、general，if：“anti-inflammatory”、“acid”，Not write medicines；The doctor will lack the necessary analysis and diagnosis and treatment to advice；The purpose of seeking consultation is not clear；Antibiotic use not record application indications；Preoperative discuss no relevance，Especially for possible surgery、Anesthesia accident prevention measures is too simple；High-risk surgery was no secondary scheme。

　　另外，还存在个别医院门诊医生不写病历，不开正规处方给病人取药；诊断选择不正确，如：病人患有宫颈息肉、子宫多发肌瘤，入院后行子宫全切除术，主要诊断却写为宫颈息肉。此外，还存在病人的出生日期与身份证信息不符，身份证号码填写不全；新生儿年龄未以分数形式记录；入院时病情、药物过敏栏、手术分级、病案质量等未以阿拉伯数字表示等现象。

In addition，There are individual outpatient doctors don't write medical record，Don't open the regular prescription for patients get medicine；Choose not to correct diagnosis，if：Patients with cervical polyp、Uterine fibroids multiple，The final total resection hospital，Primary diagnosis but write for cervical polyp。In addition，There is the patient's date of birth and id information discrepant，The id number fill in；Neonatal age was not with fractional form record；Admission condition、Drug allergy column、Surgery classification、Medical record quality in Arabic Numbers not the phenomenon such as said。

　　针对督导中存在的各种问题，江西省级卫生部门要求，各级卫生行政部门、各级各类医疗机构要进一步落实《病历书写基本规范》和新病案首页填写的要求，结合督导发现的实际问题，规范病历书写，提高住院病历的内涵质量。(记者朱正 实习生 王琼)

For all kinds of problems existing in supervision，Jiangxi provincial health department requirements，Health administrative departments at all levels、Medical institutions at various levels and to further implementation《Case file writing basic norms》And the first of cases in the new requirements，Combined with the practical problems found supervision，Standard case file writing，Improve the quality of the connotation of hospital medical records。(Reporter ZhuZheng interns WangQiong)