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教学医院的病历书写与其他医院相比,有其特殊性,它的病案质量不仅体现了教学医院的临床学术水平和管理水平,同时也是对各级医生教学工作的一个评判指标。根据上海市卫生局颁发的《病历书写基本规范(试行)》的要求,我们对我院2003年1至11月普外科所有出院病案逐一进行了检查,共
Compared with other hospitals, medical records writing in teaching hospitals has its own particularity. The quality of its medical records not only reflects the clinical academic level and management level of teaching hospitals, but also serves as a criterion for teaching doctors at all levels. According to the “Basic Medical Record Writing Standards (Trial)” issued by the Shanghai Municipal Health Bureau, we conducted a one-by-one inspection of all discharged cases of general surgery from January to November 2003 in our hospital.