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目的根据临床路径探讨制定病案书写质量监控标准。方法通过对临床路径与病历记录关系的分析;通过对临床路径具体内容的分析,以急性心肌梗死的临床路径为例,探讨根据临床路径,制定病案书写质量监控重点内容,并以此作为病案书写质量监控标准的可行性。结论根据临床路径制定病案书写质量的监控标准,是可行的,根据临床路径,制定病案书写质量监控标准,可以更好的对病案书写质量进行监控。
Objective According to the clinical pathway to explore the development of medical records quality control standards. Methods Through the analysis of the relationship between the clinical path and the record of the medical records, the author analyzed the clinical pathology and took the clinical path of acute myocardial infarction as an example to discuss the key points of quality control of medical record writing based on clinical pathology, Feasibility of quality control standards. Conclusion It is feasible to formulate the monitoring standard of medical record writing quality according to the clinical path. According to the clinical path, the quality control standard of medical record writing can be well established, which can better monitor the quality of medical record writing.