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目的:提高病案首页的书写质量,规范医疗行为,规范医疗文书记录,加强环节质量控制。方法:对我院病案首页填写存在的问题进行总结分析,提出可行性措施和建议。结果:通过对存在的问题及时反馈,为规范医疗文书书写起到了促进作用。结论:面对存在的问题,积极及时的进行总结分析,并提出可行性改进措施,才能确保规范医疗文书书写得到提高,减少医疗纠纷。
OBJECTIVE: To improve the writing quality of the first page of the medical records, standardize the medical behaviors, standardize the records of the medical instruments and strengthen the quality control of the links. Methods: To sum up and analyze the existing problems in the front page of medical records in our hospital and put forward feasible measures and suggestions. Results: Through the timely feedback on the existing problems, it has played a catalytic role in regulating the writing of medical instruments. Conclusion: In the face of the existing problems, it is necessary to make a positive and timely summarization and analysis and put forward feasible measures to improve the writing of medical documents and reduce medical disputes.