主任查房记录质量缺陷的主要原因表现为查房准备不够充分,记录流于形式,无针对性。应以抓疑难病例、危重病人、新入院及疗效不佳的病例为重点。查房内容要抓住诊断及时准确,治疗符合原则,措施合理恰当,对病情的分析思路是否条理清晰,记录是否完整及时、更改的医嘱、制定的治疗方案及需要的检查项目是否落实到位为基本内涵。 The main reason for the quality inspection of the Director’s rounds of examination is that the rounds of examination are not prepared adequately and the records are mere formality and not pertinence. Should focus on difficult cases, critically ill patients, new hospital admission and cases of poor efficacy as the focus. Rounds of content should seize the diagnosis timely and accurate treatment in line with the principles of reasonable and appropriate measures to the condition of the road is clear, the record is complete and timely, change the doctor’s advice, the development of treatment programs and the need for the inspection project in place as the basic Connotation.