我们以《医疗技术操作常规》和军区《团卫生队医疗预防工作质量标准》为依据。对九个旅团卫生队的病历书写情况进行随机抽样检查。每个卫生队十份,共计九十份。统一评分。优秀者47份,占52.2%,良好者34份,占37.8%,及格者9份,占10%。存在问题主要有以下八个方面:1、主诉不准确者10份,占11%。其中使用诊断名词的3份,占30%。重点不突出的7份,占70%。主诉不宜用诊断名词或检查结果代替 We are based on the “General Rules for Medical Technology Operations” and the “Quality Standards for Medical Preventive Work for Mission Health Corps” in the Military Region. The nine brigade health team medical record writing random checks. Ten for each health team, totaling 90. Unified score. Outstanding 47, accounting for 52.2%, 34 good, accounting for 37.8%, 9 pass, accounting for 10%. There are problems in the following eight aspects: 1, the main complaint inaccurate 10, accounting for 11%. Which use three diagnostic terms, accounting for 30%. Out of focus 7, accounting for 70%. Chief complaint should not be replaced by diagnostic terms or test results