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卫生部、国家中医药管理局颁发的病历书写基本规范实施已近10个月,本人通过病历质量监控,发现医生在日常医疗活动中,书写的病历与规范要求存在一些原则性错误。影响到医疗质量管理,甚至造成很多医疗纠纷隐患,耗费了医务人员和医院管理者大量的时间和精力。为此,将病历书写中易出现错误的有关事项;并结合中华医院管理学会病案管理专业委员会病案质量监控委员会制订的全
The basic rules for the writing of medical records issued by the Ministry of Health and the State Administration of Traditional Chinese Medicine have been implemented for nearly 10 months. I have monitored the quality of medical records and found that there are some principle errors in medical records written by doctors during their daily medical activities. Affecting the management of medical quality, even causing a lot of hidden troubles in medical disputes, has consumed a lot of time and energy for medical staff and hospital administrators. To this end, the medical records will be written in error-prone matters; and in conjunction with the medical record management committee of the Chinese Hospital Management Association, the Medical Record Quality Control Committee