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随着全国医院等级评审工作的完成和当前医疗改革及医疗保险制度的实施,全民法制观念不断提高,建立和完善病案质量监控管理工作已提到议事日程,而病案质量主要从病案书写中反映。建立全国统一的病案书写要求与评分标准已成为目前病案质量监控管理工作急需解决的问题。全国统一标准病历出台既迫切又艰巨,一定要正确、灵活运用普遍性及特殊性辩证关系。结合自己10多年来工作实践谈谈病案书写要求及具体措施。
With the completion of the national hospital grade review and the implementation of the current medical reform and medical insurance system, the concept of universal legal system has been continuously improved. The establishment and improvement of medical record quality control and management has been mentioned on the agenda, and the quality of medical records has mainly been reflected in the written medical records. The establishment of a unified nationwide medical record writing requirements and scoring standards has become an issue urgently needed to be solved in the current medical record quality control and management work. The introduction of a unified national standard medical record is both urgent and arduous. We must make the correct and flexible application of the dialectical relationship of universality and particularity. Combined with his own work over the past 10 years to talk about the medical record writing requirements and specific measures.