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目的通过对基层医院病历书写的现状进行分析,从病案管理的角度加以控制及防范医疗纠纷,有效提高医疗质量,保障医疗安全。方法对考核病历中存在的书写问题进行归纳总结,找出常见问题及解决方法。结果加强病案质量监控对防范医疗纠纷切实可行。结论加强基层医院医师病历的质量管理,完善《病历书写基本规范》,可以有效防范医疗纠纷。
Objective To analyze the status quo of medical records writing in primary hospitals, to control and prevent medical disputes from the perspective of medical records management, to effectively improve medical quality and ensure medical safety. Methods Summarize and summarize the writing problems existing in the examination medical records, and find common problems and solutions. Results Strengthening the quality control of medical records to prevent medical disputes is feasible. Conclusion Strengthening the quality management of medical records of primary hospital physicians and perfecting “the basic norms of medical record writing” can effectively prevent medical disputes.