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《病历书写基本规范》第七版《诊断学》和《三级综合医院评审标准实施指南》是指导病历书写的权威性规范性文献。但三者对住院病案内容的划分存在较多不一致、不合理问题,这对于病历书写教学与管理和病案学科建设均产生不利影响,使得这些文献的权威性受到挑战。本文在对这些问题讨论的基础上,提出一种新的划分方法:先按书写者身份将住院病案一级划分为5大类:临床医师的记录、(护理)助产人员的记录、辅助科室医务人员的记录、各类医务人员共同完成的记录和医患双方共同完成的记录,然后再按记录时间或记录性质进行细分。
“Basic Medical Records Writing,” the seventh edition of “Diagnostics” and “Third-level Comprehensive Hospital Accreditation Standards Implementation Guide” is to guide the medical records authoritative normative literature. However, there are many inconsistencies and unreasonable problems in the division of the contents of inpatients’ medical records, which have adverse effects on teaching and management of medical record writing and the construction of medical records, which makes the authority of these documents challenged. Based on the discussion of these issues, this paper proposes a new method of division: firstly, the first grade of inpatient medical records is divided into five categories according to the writer’s status: records of clinicians, records of (nursing) midwifery personnel, auxiliary departments Medical staff records, all kinds of medical staff to complete the record and both doctors and patients to complete the record, and then press the time of recording or the nature of the breakdown.