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临床工作中上级医师有责任审查下级医师书写的病历,但是病历审查占据上级医师大量的时间与精力,加之审查模式及相关政策的限制,病历审查质量控制存在着一定的难度。通过研究病历审查必要性的同时,从上级医师的立场分析临床实际工作中病历审查的难点,从主观及客观两方面指出影响病历审查质量的相关因素。对此,建议上级医师扭转以书面为主的审查模式,强化临床医师诊疗思维的培训,并开展多种形式的病历教学,运用适合个人教学特色及针对性较强的思维培训等多种模式,关注重点医师及重点内容,完善病历书写质量的检查标准和奖惩制度,以期提高上级医师病历审查质量,从而提升病历内涵。
In the clinical work, the superior physicians have the responsibility to examine the medical records written by the subordinate physicians. However, the medical records review occupy a large amount of time and energy of the superior physicians. Combined with the limitations of the examination mode and relevant policies, there is some difficulty in the quality control of the medical records review. By studying the necessity of medical record reviewing, the author analyzes the difficulty of medical record review in clinical practice from the position of superior physician, and points out the factors that influence the quality of medical record review both subjectively and objectively. In this regard, it is recommended that the higher physician reverse the written review mode, strengthen the training of clinicians thinking and medical treatment, and carry out various forms of medical record teaching, use of individual teaching characteristics and targeted thinking training and other modes, Focus on the key doctors and key content, improve medical records writing quality inspection standards and reward and punishment system, in order to improve the quality of medical records review, thereby enhancing the connotation of medical records.