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病案是医疗工作的原始记录,是临床总结的取材依据,是医院等级评定的必检项目,也是晋升高级卫生技术职称必须送审的关键材料。因此提高病案书写质量,是卫生技术人员的职责,也是医院的大事。而作为晋升职称的送审病案,则除一般要求之外,还要突出反映送审者的学识水平和工作能力,其书写要求又要有所提高。因此笔者就送审病案的有关要求及如何提高病案书写质量谈谈自己的看法。
The medical record is the original record of medical work. It is the basis for the clinical summary. It is a mandatory item for the assessment of hospital ranks. It is also a key material for the advancement of senior health technical titles. Therefore, it is the duty of health technicians to improve the writing quality of medical records. It is also a major event for hospitals. In addition to the general requirements, as a medical examination case for promotion, it is also necessary to highlight the level of knowledge and ability of the person submitting the trial, and their writing requirements must be improved. Therefore, the writer talks about his own opinions on the relevant requirements for medical records and how to improve the writing quality of medical records.