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目的分析目前进修医师和研究生书写病历的资格认定与管理现状、存在问题、产生原因、提出对策,从而提高病历书写质量。方法以《病历书写基本规范(试行)》为标准参照本单位的规章制度和管理细则,对本医院的现状进行分析研究。结果目前的资格认定与管理存在许多问题,既影响医院的病历书写水平的提高,对进修医生和研究生的学习深造也不利;而产生的原因也是多方面的,既有制度上的,也有书写人员自身素质和带教老师疏于审核造成的。结论在新形势下应该积极应对,对进修人员等要严格要求、强化管理,同时制度建设也需要与时俱进。从病历书写的基本要求入手,严格把关,在资格认定前认真修改,取得资格后还要经常督促检查,从源头上杜绝缺陷病历产生的根源。既保证三级教学医院的病案质量,又不耽误医学人才的培养使用和基层医疗技术水平提高。
OBJECTIVE: To analyze the status quo, problems, causes and countermeasures of medical records and writing medical records of current graduates and postgraduates so as to improve the quality of medical record writing. Methods The basic norms of medical records (Trial) as a standard with reference to the unit’s rules and regulations and management rules, the hospital’s status quo analysis. Results There are many problems in the current accreditation and management, which not only affects the improvement of hospital medical records writing but also unfavorable effects on the study of advanced doctors and postgraduates. There are many reasons for this. There are both institutional and written personnel Own quality and teacher negligence audit caused. Conclusion In the new situation, we should actively respond to the requirements of the training staff and other requirements, strengthen management, at the same time institution building also need to advance with the times. Beginning with the basic requirements of medical record writing and strictly checking before serious changes in qualifications, but also often supervise and inspect the qualifications, from the source to eliminate the root causes of defective medical records. It not only guarantees the medical record quality of tertiary teaching hospitals, but also does not delay the training and use of medical professionals and the improvement of primary medical technologies.