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放射治疗是恶性肿瘤的重要治疗手段之一,放射治疗科的病历书写既要体现恶性肿瘤的疾病特点及诊治过程,还应详实、清晰地记录放射治疗计划及治疗过程,因此,病历书写是放射治疗科住院医师培训的重要组成部分。本文详细阐述病历书写培训中的教学内容,结合学科特点,从恶性肿瘤及放射治疗专业知识两方面归纳总结病历书写的主要内容、要求及质控原则,并强调病历质量管理的重要性,提出改善病历书写质量的有效方法。1
Radiotherapy is one of the important treatment of malignant tumors, radiotherapy department of the medical records should not only reflect the characteristics of the disease and diagnosis and treatment of malignant tumors, but also a detailed and clear record of radiotherapy planning and treatment process, therefore, the medical record is radiation Treatment residency training an important part. This article elaborates the contents of teaching in medical record writing training, summarizes the main contents, requirements and quality control principles of medical record writing from two aspects of malignant tumor and radiation therapy expertise, and emphasizes the importance of medical record quality management Effective method of medical records writing quality. 1