| 病案书写质量分析与对策 |
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| 引用本文： | 于弘,赵莉.病案书写质量分析与对策[J].中国病案,2011,12(4):24-25. |
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| 作者姓名： | 于弘 赵莉 |
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| 作者单位： | 1. 黑龙江省佳木斯市中心医院,佳木斯市,154002
2. 黑龙江省医院,哈尔滨市,150036 |
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| 摘 要： | 目的提高住院病案书写质量,使医院、医务人员、患者三方的权益得到法律保障。方法检查某医院2010年第一季度出院病人病案并进行分析。结果住院病案书写质量,与书写医师性别、职称、科室等因素有关。结论住院病案的书写仍然存在某些缺陷,需要采取多种对策,提高病案书写质量。
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| 关 键 词： | 病案 书写质量 对策 |
Analysis and Countermeasures on Medical Records Writing Quality |
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| Yu Hong,Zhao Li.Analysis and Countermeasures on Medical Records Writing Quality[J].Chinese Medical Record,2011,12(4):24-25. |
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| Authors: | Yu Hong Zhao Li |
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| Institution: | Yu Hong,Jiamusi Central Hospital of Heilongjiang Province,Jiamusi 154002,Zhao Li,Heilongjiang Provincial Hospital,Ha'erbin 150036,Heilongjiang Province,China |
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| Abstract: | Objective To improve the medical record writing quality,and make sure the rights and interests of hospital,medical staff,and patients are guaranteed by law.Methods Check and analyze medical records of discharged patients in first quarter of 2010.Results The writing quality of medical record is relate to physician gender,job title,department and other factors.Conclusion There are still some shortcomings in medical record writing,various measures should be adopt to improve the writing quality of medical recor... |
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| Keywords: | Medical record Writing quality Countermeasures |
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