目的探讨住院病历书写中存在的问题及改进方案;方法对住院病历书写,尤其是打印病历中出现的争议及相关因素进行分析。结果入院记录中诊断项目设置、三级检诊记录、病程记录分页、页码排序、病史陈述者的可靠性注明以及医用植入器材条形码标签等细节,应当加以明确。结论住院病历书写规范的细则和各类文书范本尚需充实完善。 Objective To explore the problems existing in the writing of inpatient medical record and the improvement plan. Methods Analyze the controversy and correlative factors in the writing of inpatient medical record, especially printed medical record. Results The details of the setting of the diagnosis items, the level 3 examination records, the page layout of the disease records, the reliability of the medical history statement, and the barcode labels of the medical implants should be clarified in the admission records. Conclusions The details of inpatient records writing norms and various types of paperwork still need to be improved.