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文章分析了病案书写过程中存在的问题,如住院病案首页填写不全、入院记录内容简单、术前讨论不完整、手术记录书写不及时等。并就其原因进行了讨论,主要是重视程度不够、法律意识淡漠等。提出应通过强化法律意识,提高认真书写病案的自觉性,激发病案书写的内生动力以及建立激励机制,促进医师通过病案的书写建立起缜密的临床思维,形成一种终身不改的良好行医习惯。
The article analyzes the existing problems in the process of medical record writing, such as incomplete entry page of hospitalized medical records, simple record of admission, incomplete preoperative discussion, incomplete operation record writing and so on. And discussed the reasons, mainly the degree of attention is not enough, indifferent legal awareness. It is suggested that we should strengthen the awareness of the law, improve the conscientiousness of seriously writing the medical record, stimulate the endogenous motivation of the medical record writing, and establish the incentive mechanism to promote the doctors to establish meticulous clinical thinking through the writing of the medical record so as to form a good habit of practicing medicine .