摘要
目的通过典型院感病历的分析,浅析临床医生的感控思维,以期提升临床医生感控意识和能力。方法从某市22家市属医院按比例报送的2021年度的院感病历中,每家抽取1~2例典型病历,分析院感风险评估与干预、病原学送检、多重耐药菌防控及院感病历书写等方面的内容。结果共抽取典型院感病历30份,其中有院感风险评估及干预相关内容记录的病历占40.00%;抗菌药物治疗前病原学送检率为43.33%;多重耐药菌接触隔离医嘱开具率为15.38%;院感诊断、病原学结果、抗菌药物调整记录缺如或分析不完善的病历分别占70.00%、59.09%、73.33%。结论院感风险评估及干预意识有待提高;抗菌药物治疗前病原学送检率未达标;多重耐药菌接触隔离医嘱开具率较低;院感病历书写存在诸多问题。以上问题反映出临床医生感控思维不够全面,而系统性感控思维的培养有赖于临床医生、科室、院感专职人员和医院管理者的共同重视、参与及长期不懈地努力。
OBJECTIVE To simply analyze the infection control ideas of the clinicians through typical medical records of nosocomial infection so as to intensify the clinicians′awareness and ability of infection control.METHODS The medical records of nosocomial infection of 2021 were reported and submitted on a pro rata basis from 22 municipal hospitals,and 1 or 2 typical medical records were extracted from each of the hospital.The contents of the medical records,including assessment of risk and interventions to nosocomial infection,etiological submission,prevention and control of multidrug-resistant organisms and writing of medical records,were observed.RESULTS Totally 30 typical medical records of nosocomial infection were extracted,40.00%of which were regarding to the contents of assessment of risk and interventions to nosocomial infections.The etiological submission rate was 43.33%before the antimicrobial therapy,and the rate of doctor′s advice on contact isolation of multidrug-resistant bacteria was 15.38%.The proportions of medical records with absence or incomplete analysis of records of diagnosis of nosocomial infection,etiological result and adjustment of antibiotics were 70.00%,59.09%and 73.33%,respectively.CONCLUSION The awareness of assessment of risk and intervention to nosocomial infection needs to be improved.The etiological submission rate is not qualified before the antimicrobial treatment.The rate of doctor′s advice on contact isolation of multidrug-resistant organisms is low.There are a variety of problems in writing of the medical records.The above problems reflect the clinicians′poor thinking on the infection control.Systematic cultivation of thinking on infection control may depend on the joint efforts of the clinicians,professional staff of infection control and hospital administrators.
作者
咸鹏
武迎宏
吴圣
刘潇
马丽君
任洁
蒋俭
曹洋
IAN Peng;WU Ying-hong;WU Sheng;LIU Xiao;MA Li-jun;REN Jie;JIANG Jian;CAO Yang(Beijing Tongren Hospital,Capital Medical University,Beijing 100730,China;不详)
出处
《中华医院感染学杂志》
北大核心
2025年第2期302-305,共4页
Chinese Journal of Nosocomiology
基金
北京市重大疫情防治重点专科项目(XKB2022B101)。
关键词
医院感染
病历分析
临床医生
感控思维
Nosocomial infection
Medical record analysis
Clinician
Thinking on infection control
