论文部分内容阅读
我俩为了提高病历书写质量从而提高医疗质量,检查了53疗养院和179医院的部分病历,从中可以看出,该两院在病历书写上还存在着许多急待解决的问题。这些问题对有些医院和部队医疗机关,也许有着参考的意义,特提出商讨。这两个医院的部分军医,认为当前住院的患者多数是慢性病,没啥好写的,因此对入院病历书写过于简单,竟有的病历只用半页或一页,因此这些病历就不能说明一个疾病的全貌。这种现象的实质是忽视慢性病。
In order to improve the quality of medical record writing and improve the quality of medical care, we examined some of the medical records of Sanitarium No. 157 and No. 179 Hospital. It can be seen from this that there are still many problems to be solved in the medical records of the two hospitals. These questions may have reference significance for some hospitals and military medical institutions. Some of the military doctors in these two hospitals think that most of the patients who are hospitalized are chronic diseases and are not well-written. Therefore, it is too simple to write medical records for admission. The actual medical records only use half a page or one page. Therefore, these medical records cannot explain one. The whole picture of the disease. The essence of this phenomenon is the neglect of chronic diseases.