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针对神经外科医师在病历书写过程出现分析问题片面、病历内涵缺乏、时限错误、内容缺项、复制黏贴错误等问题。通过强化住院医师“三基”训练,规范病历书写,突出主治医师的监管职能,加强病历质量“三级”监督、落实病历质量持续改进制度等系列措施,对规范诊疗行为,提高病历书写质量,提升病历内涵,取得了良好的效果。
Neurosurgeons in the medical record writing process appeared one-sided analysis of the problem, lack of medical records, time limit error, lack of content, copy and paste errors and other issues. By strengthening the training of residency “Three Basics ”, standardizing medical records writing, highlighting the supervisory functions of attending physicians, strengthening the quality of medical records “three ” supervision, implementing continuous improvement system of medical records and other measures, Medical record writing quality, improve medical records, and achieved good results.