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| 病案书写规范实例分析 | |
| 引用本文： | 欧晖,谭小燕,李凌. 病案书写规范实例分析[J]. 中国病案, 2013, 0(8): 16-17 |
| 作者姓名： | 欧晖 谭小燕 李凌 |
| 作者单位： | 广州市第一人民医院病案室,广州市510180 |
| 摘 要： | 本文以案例分析的方法,针对由于病案首页填写错误、书写不及时、内容缺陷、记录不完整等问题而引起医患纠纷的情况进行分析,并提出规范病案书写;保证病案的完整性;健全病案质控体系等有效措施,从而有效地防范医患纠纷。 |
| 关 键 词： | 病案书写 规范 分析 |
Case Analysis on Writing Standard of Medical Record |
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| Ou Hui,Tan Xiaoyan,Li Ling. Case Analysis on Writing Standard of Medical Record[J]. Chinese Medical Record, 2013, 0(8): 16-17 | |
| Authors: | Ou Hui Tan Xiaoyan Li Ling |
| Affiliation: | , Department of Medical Record, The First People＇ s Hospital in Guangzhou City, Guangzhou 510180, Guangdong Province, China |
| Abstract: | Based on the method of case analysis, this article analyzed the medical disputes caused by problems such as error medi- cal record home page filling, not timely writing, content defects, incomplete recording, and put forward some effective measures to standard medical record writing, ensure the integrity of the medical record as well as complete the medical record quality control sys- tem, thus effectively prevent medical disputes. |
| Keywords: | Medical record writing Specification Analysis |
| 本文献已被 CNKI 维普 等数据库收录！ | |