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目的探讨临床医师病历书写技能培养,提高病历书写质量方法。方法实行新毕业医师轮流到病案室培训,学习与病历相关的法律法规,病历书写规范、住院病历质量评分标准、国际疾病分类、病案首页填写说明等。结果增强了医师病历质量意识和法律意识,掌握国际疾病分类对疾病诊断的规则、病案首页填写要求。结论新毕业医师轮训是完善质量管理,促进病历质量持续改进的有效途径。
Objective To explore the method of clinical physician writing skills writing and improve the writing quality of medical records. Methods The newly graduated physicians took turns to the case record training, learning laws and regulations related to the medical records, medical records writing norms, the quality standard of inpatient medical records, the international classification of diseases, the first page of medical records and so on. The results enhance physicians medical awareness of quality and legal awareness, grasp the international classification of diseases on the diagnosis of disease rules, the first page of medical records to fill in requirements. Conclusion The rotation training of newly graduated physicians is an effective way to improve quality management and promote continuous improvement of medical record quality.