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为了适应《医疗事故处理条例》实施的新形势,把病历书写与病案管理纳入科学化和法制化管理的轨道,江苏省卫生厅委托江苏省医院管理学会对《病历书写规范》进行了第三次修订,并四次出版。这对统一病历格式、规范书写要求、提高书写质量和医务人员的业务水平、加强医疗质量控制都起到了积极作用。但这四版的规范对“住院证”只是在住院病案首页(表格式记录式样)中以小字样用括号以“粘贴住院证处”的方式提及,而住院证的式样及如何填写都未详细介绍。住院证是门诊医师与住院处及病区联系的重
In order to adapt to the “Medical Malpractice Ordinance” the implementation of the new situation, the medical record writing and medical record management into the track of scientific and legal management, Jiangsu Provincial Department of Health commissioned the Jiangsu Provincial Hospital Management Institute of “medical records writing norms” for the third time Revised, and published four times. This has played a positive role in unifying medical records format, standardizing writing requirements, improving writing quality and medical staff’s business level, and strengthening medical quality control. However, the norms of the four editions refer to “Inpatient Card” only mentioned on the first page of inpatient medical records (tabular record format) with the brackets in the form of “Ply Hospitalization Card”, and the type of hospitalization card and how to fill in it Detailed introduction Hospitalization card is outpatient clinic and ward contact with the ward