简述病历书写常见错误

目的帮助临床医师提高病历书写质量。方法笔者将多年来在对终末病案质量控制工作中，将临床医师病历书写中的常见错误及容易忽略的问题加以总结、分析。结果临床医师书写的住院病历中尤其是入院记录及病程记录部分出现的错误及容易忽略的问题较多。结论病历作为医疗活动信息的主要载体，不仅是医疗、教学、科研的第一手资料，而且也是医疗质量、技术水平综合的依据。发生医疗争议时，医疗机构和患者都有举证的义务。临床医师必须加强对病历书写重要性的认识，重视病历书写，保证病历书写质量。

Brief introduction to the contain mistakes in medical record writing

Objective To help the clinical physicians improve their medical record writing. Methods The real cases of the most commonly made mistakes and frequently ignored problems are summarized and analyzed. Results Many mistakes were often seen in the medical records written by the physician,particularly the sections of hospitalization and present illness history.Conclnsions As the main vehicle of the healthcare information, medical records are not only the first - hand material for medical care practice, teaching and research, but also the evidence of the quality and skills of the medical service. Physicians must attach great importance to the medical records writing.