一份完善的死亡证明：通过简单的教育措施提高效能。
A good death certificate: improved performance by simple educational measures.
作者信息
Selinger Christian P, Ellis Robert A, Harrington Mary G
机构信息
Department of Medicine for the Elderly, Airedale General Hospital, Keighley, UK.
出版信息
Postgrad Med J. 2007 Apr;83(978):285-6. doi: 10.1136/pgmj.2006.054833.
BACKGROUND AND AIMS
The initial aim of this audit was to determine whether information on death certificates is correct and all legal requirements are met. As shortcomings were found, educational measures were undertaken and the effect of those was measured by a re-audit.
METHOD
All death certificates issued during a 4-month period within the elderly care department of a district general hospital were retrospectively audited. A re-audit was performed later the same year over a 3-month period.
RESULTS
19 (13.6%) of 140 certificates issued during the initial 4-month period could not be shown to meet the statutory criteria, as no evidence was found that these patients were attended by the issuing medical officer. Minor errors and omissions were found in 58.6% of certificates. Following education about these problems, there was a significant improvement in death certification. Only 2 (2.4%) of 85 certificates issued in the re-audit period did not meet the statutory criteria (p = 0.01) and minor errors and omissions occurred in 20%.
CONCLUSION
The incidence of unsatisfactory death certificates within a hospital setting is high. Increased education and better documentation leads to improvements in accuracy and legitimacy.
背景与目的
本次审核的最初目的是确定死亡证明上的信息是否正确以及是否符合所有法律要求。由于发现了不足之处，因此采取了教育措施，并通过重新审核来衡量这些措施的效果。
方法
对一家地区综合医院老年护理部在4个月内开具的所有死亡证明进行回顾性审核。同年晚些时候，在3个月的时间内进行了重新审核。
结果
在最初4个月期间开具的140份证明中，有19份（13.6%）无法证明符合法定标准，因为没有证据表明这些患者由开具证明的医务人员诊治过。在58.6%的证明中发现了小错误和遗漏。在对这些问题进行教育后，死亡证明开具情况有了显著改善。在重新审核期间开具的85份证明中，只有2份（2.4%）不符合法定标准（p = 0.01），小错误和遗漏发生率为20%。
结论
医院环境中死亡证明不合格的发生率很高。加强教育和完善文件记录可提高准确性和合法性。
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