目的 调查医疗文书填写现状并探讨其对患者满意度之间的影响。 方法 2012年10月－12月以呼吸内科住院的患者为调查对象，调查其医疗文书完成情况，统计医疗文书缺项数目。同时参考国内外患者满意度研究，自制满意度调查表，调查患者对医务人员满意度；分析医疗文书缺项数目对患者满意度的影响。 结果 研究共纳入151例患者，共有126份医疗文书存在不同程度填写缺陷，占83.44%，平均缺项（11.58 ± 11.63）条。总体患者就医满意度为6.85分，与医疗文书缺项数目呈现负相关性（R=?0.602，P=0.001）。患者性别、年龄、文化程度、付费方式和住院天数与患者满意度无相关性。 结论 医疗文书缺项数目较多、完成质量不高。需要加强医务人员对于医疗文书完成质量的重视程度。
ObjectiveTo explore the clinical effect of the whole-course integrated care and traditional nursing in perioperative period of percutaneous needle biopsy. MethodsA total of 198 patients treated between May 2012 and March 2013 were randomly divided into the traditional care group (control group) and the whole-process integrated care group (experimental group). Then, we compared between the two groups in terms of pain and anxiety levels, qualified rate of specimen and incidence of postoperative complications. ResultsQualified rate of specimen in the experimental group (97.94%) was significantly higher than that in the control group (85.15%) (χ2=10.312, P=0.001). After surgery, the rates of pneumothorax and bleeding were 3.09% and 4.12% in the experimental group, and 11.88% and 14.85% in the control group; the pain score of the experimental group was 4.25±1.38, and 6.12±1.87 in the control group. One hour before and 8 hours after surgery, the anxiety scores were 11.16±3.29, 8.47±2.52 in the experimental group, respectively, and were 16.26±3.17, 12.12±3.26 in the control group, respectively. There were significant differences between the two groups in all the above indexes (P<0.05). ConclusionWhole-course integrated care can significantly reduce pain and anxiety levels and the incidence of postoperative complications and improve the success rate of percutaneous needle biopsy.