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一、背景 多年以来在综合医院都强调要按照“病案书写规范”书写住院病案(完整大病案或住院志),只有少数专科医院才允许使用表格式病案。随着高科技的渗入,数字医院也呼之欲出,临床医师对改革书写住院病案形式的呼声也越来越迫切了。 广东省人民医院近几年的出院病案为2.7万份次/年,大体上使用的病案有两大类:通科病案和专科表格病案。后者除了包括《广东省病案书写规范》中所含的神经内外科、少儿科、产科、眼科、护理病案
I. Background For many years in general hospitals, emphasis has been placed on writing an inpatient medical record (complete case or hospitalization record) in accordance with the “case writing guidelines”. Only a few specialized hospitals are allowed to use the tabular format. With the infiltration of high technology, digital hospitals are becoming more and more appealing, and clinicians are increasingly pressing for reforms to write inpatient medical records. Guangdong Provincial People’s Hospital has discharged 27,000 medical cases/year in recent years. The medical records used in general have two major categories: general medical records and specialist form medical records. The latter includes neurosurgery, pediatrics, obstetrics, ophthalmology, and nursing care in addition to the “Guidelines for Writing Medical Records in Guangdong Province.”