实习医师心内科病历书写缺陷与防范

目的了解实习医师心内科病历的质量现状，探讨提高实习医师心内科病历质量的方法。方法根据《病历书写基本规范》要求，检查某三级甲等医院2011—2013年实习医师书写的心内科病历。结果心内科病历普遍存在书写不完整、不规范问题，其中缺陷率最高的3项内容依次是现病史（69．7％）、系统回顾（65．6％）和主诉（61．1％）。结论通过加强心内科病历特点及相关法律知识培训、制定心内科病历评估标准和量化考评方法、针对常见问题进行点评和讲解等措施，可以增强实习医师的心内科病历质量意识及法律意识，有利于提高病历内涵质量，防范医疗纠纷。

Defects in the Quality of Medical Records of Cardiology Writing in Clinical Internship and the Countermeasures

Objective To understand the status of the quality of medical records of cardiology writing in clinical internship and to ex- plore the key points of quality control of it. Methods All of medical records of cardiology writing in clinical internship in a third-class A-grade hospital from 2011 to 2013 were studied and analyzed according to the standard of ＂Specification for Medical Records Writing＂. Results Incomplete or non-standard medical records concerned with cardiology were found commonly. The highest rate of defects in the top three was history of present illness （69.7%）, review of systems （65.6%）, and chief complaints （61.1%）, respectively. Conclusions It is necessary to strengthen the training in writing medical records and related rules for interns, develop criteria of evaluation for cardiology, ira-prove method of quantitative evaluation, comment and explain the common problems, so as to enhance the consciousness of medical record quality and related laws of interns, and contributes to improve the quality of medical records and prevent medical disputes.