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通过23所医院的545份病历检查,我们认为目前病历书写中还存在不少问题。概括起来有3个方面:即对病历书写重视不够,书写不认真,医学基础理论知识不足,基本功不过硬;以及语文水平较低,表达不准确。其中以第二个方面的问题较多,这也是今后加强病历书写质量的重点。现分析如下。 1.对病历书写重视不够,书写不认真 (1)病历首页填写不全或治疗经过记载简单者244份次,占44.7%。病程记录未按要求及时记载者30份次,占5.5%。
Through the examination of 545 medical records in 23 hospitals, we think there are still many problems in the current medical record writing. To sum up there are three aspects: that is, insufficient attention to the medical record writing, writing is not serious, lack of basic medical knowledge, basic skills is not perfect; and the language level is low, the expression is not accurate. Among them, there are more problems in the second aspect, which is also the focus of strengthening the quality of medical record writing in the future. Analysis is as follows. 1. The medical record is not enough emphasis on writing, writing is not serious (1) medical records home page is incomplete or recorded 244 simple records, accounting for 44.7%. Records of the disease were not recorded in time as required 30 times, accounting for 5.5%.