病案质量是反映科室医疗质量和学术水平的重要标志之一,是反映临床医师基本技能和工作态度的一个重要方面。 一、存在问题与原因 如入院病历书写不及时,格式不规范,内容不完整;病程记录内容贫乏,反映病情不全面,缺乏分析判断;上级医师修改不及时,欠认真;病历顺序杂乱,缺项或少页等。究其原因,从客观上分析,临床 The quality of medical record is one of the most important symbols that reflect the medical quality and academic level of the department. It is an important aspect that reflects the clinician’s basic skills and working attitude. First, the existing problems and causes such as medical records on admission is not written in time, the format is not standardized, the content is incomplete; the course record is poor, reflecting the disease is not comprehensive, lack of analysis and judgment; not timely revision of the physician, due to serious; Or less pages and so on. The reason, from the objective analysis, clinical