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目的对社区医师书写病历的质量进行调查和分析,查找存在的突出问题,提出改进的对策。方法根据2010年浦东新区卫生工作者协会组织专家对全区44家社区卫生服务中心病历质量考核的汇总情况进行分析。结果社区医师病历书写的质量还存在不少的问题,住院病历更为突出,如字迹潦草无法识辨;存在涂改现象;病史记录不清;病例资料不完整等。结论不少社区医师对病历书写质量的重要性还没引起足够的重视,书写病历流于形式,不能真正反映患者病情变化以及诊疗的全过程。这样的医疗服务质量低下,且存在着很大的医疗风险。因此,对社区医师开展病历重要性教育与能力的培训非常重要和紧迫。
Objective To investigate and analyze the quality of written medical records of community physicians, find out the outstanding problems and put forward the countermeasures for improvement. Methods According to the 2010 Pudong New Area Health Workers Association organized experts on the 44 community health service centers in the district medical records quality assessment of the summary. Results There were still many problems in the quality of medical record writing in community physicians. In-patient medical records were more prominent, such as ill-written illegible characters, altered phenomenon, ill-defined history records, incomplete case data and so on. Conclusion Many community physicians have not paid enough attention to the quality of medical record writing. Writing medical records is a mere formality and can not truly reflect the patient’s condition and the whole process of diagnosis and treatment. The quality of such medical services is low and there is a significant medical risk. Therefore, it is very important and urgent to train community physicians on the education and ability of medical record importance.