几年来門診病历的記录頗不一致,大都簡陋,而致影响医疗質量。对于見习医师和实习医师的病历也沒有一定的标准和要求,因而也影响教学質量。为了进一步提高医疗教学質量,門診病历記录有重新提出商討的必要。但門診工作具有一定的时間性和計划性,应力求簡明,今将其重点內容要求簡述如下: Outpatient medical records in recent years records quite inconsistent, mostly simple, which affects the quality of medical care. There is also no standard and requirement for the trainee’s and intern’s medical record, which also affects the teaching quality. In order to further improve the quality of medical education, outpatient medical record has the need to re-discuss. However, outpatient work has a certain time and planning, should strive to concise, the key content of the requirements outlined below are as follows: