| 关于住院病案修改和修改原则的讨论 |
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| 引用本文： | 李小平,侯树忠,耿建英,刘福勇. 关于住院病案修改和修改原则的讨论[J]. 中国病案, 2007, 8(1): 8-11 |
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| 作者姓名： | 李小平 侯树忠 耿建英 刘福勇 |
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| 作者单位： | 050082,石家庄,解放军白求恩国际和平医院 |
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| 摘 要： | 文章重点围绕住院病历的修改问题提出以下几点意见:1住院病历是非常重要的医疗资料,修改是保证书写质量的基本方法2修改的形式和方法依据住院病历质量内涵的不同有不同的要求3修改是通过多种形式和不同级别医务人员共同完成4修改必须在一定的限制和原则基础上进行。
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| 关 键 词： | 住院病案 书写质量 修改 |
A Discussion about the Modification of Medical Record and the principles |
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| Li xiaoping,Hou shuzhong,Geng jianying,Liu fuyong. A Discussion about the Modification of Medical Record and the principles[J]. Chinese Medical Record, 2007, 8(1): 8-11 |
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| Authors: | Li xiaoping Hou shuzhong Geng jianying Liu fuyong |
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| Abstract: | We present the views about modification of medical record, the points of the view are: (1) medical records are very important medical information, the modification of the medical records is a basic method to guarantee their quality; (2) different modification criterions and methods are needed based on the contents of medical records quality; (3) the modifications are completed with medical staff of different classes through multi -forms; (4) the modifications of medical records must be implemented within certain restrictions and follow the principles. |
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| Keywords: | Medical records Quality of Medical records Modification |
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