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本文针对“病历书写基本规范[1]”中病程记录的部分书写要求提出几点修改讨论意见:1突出重症患者的病程记录要求。2限定日常记录次数的“基本原则”和“最低标准”。3对上级医师查房记录做出具体的时间和次数要求。4在病程记录中增加“补充诊断和更正诊断”。
In this paper, some amendments are proposed for the writing requirements of the course records in the “Basic Rules for Writing Medical Records[1]”: 1 To highlight the record of the disease course of critically ill patients. 2 Limit the “basic principles” and “minimum standards” for the number of daily records. 3 Make specific time and frequency requirements for superior doctor rounds records. 4 Add “supplementary diagnosis and correction diagnosis” to the course record.