摘要
目的规范病历书写,提高病案质量。方法对病历书写中存在的缺陷及原因进行分析。结果不规范的书写导致病历资料不完整,直接影响了病案的质量,一但发生医疗纠纷,将对医院的举证不利造成巨大的经济损失。结论强化岗前培训,提高医务人员的法律意识和责任心,将培训和质量监督相结合,以促进病历书写水平的提高。
Objective Writing medical records is the basic skill of clinicians,and standardized writing can improve the quality of medical records.Methods To put the ＂writing standardization of medical records in Hubei province＂ system into effect,medical quality control should be strengthened.In this article,deficiencies and causes in medical records were analyzed.Results Non-standard writing of medical records lead to incomplete data,directly affecting the quality of medical records,which would bring detrimental influence on hospital and cause enormous economic losses once medical dispute occurred.Conclusion Medical records quality reflects medical quality and technical level,writing of medical records is a process that medical quality was formed and improved.Through pre-job training,improving legal awareness and responsibility of medical personnel,and combining the training with quality surveillance,medical overall level can be improved.
出处
《中国病案》
2010年第7期28-29,21,共3页
Chinese Medical Record
