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检验报告单是病历的重要组成部分之一,其报告的信息可直接或间接为临床医师提供诊断、鉴别诊断、治疗、预后的依据,并且是发生医疗纠纷的有力举证之一。因此,检验报告单的客观真实性、准确性、完整性尤为重要。当前在检验报告单中存在着一些问题:如基本信息录入错误、数据不准确、报告单丢失等。为此,谈谈在这方面的管理体会。
The test report form is one of the important parts of the medical record. The information reported in this report can directly or indirectly provide clinicians with the basis for diagnosis, differential diagnosis, treatment and prognosis, and is one of the powerful evidences for medical disputes. Therefore, the objective truth of the test report, accuracy and completeness is particularly important. Currently there are some problems in the test report: such as basic information input errors, inaccurate data, reports and other lost. To this end, talk about the management experience in this regard.