呼吸内科实习医师入院病历书写的问题与分析

目的：回顾性分析呼吸内科实习医师书写入院病历的问题，探讨提高实习医师书写质量的方法。方法对2013年3—12月382份呼吸内科轮转实习医生书写的入院病历进行回顾性分析，根据2010年颁布的《病历书写基本规范》要求检查。结果检查的入院病历中，各个部分（一般信息、主诉、现病史、体格检查、辅助检查、初步诊断）均存在相应的问题，其中存在问题最多是现病史部分（36．1％），存在问题最少的是辅助检查部分（4．2％）。结论实习医师书写呼吸内科入院病历仍存在问题，因此加强法律法制知识教育，培养专业能力和素质，提高带教老师教学意识，对提高实习医师书写入院病历的质量非常重要。

Analysis on problems of admission note written by interns in respiratory medicine department

Objective To retrospectively analyze problems of admission note written by interns in respiratory medicine department , and explore ways of improving writing quality of the admission note of interns . Methods A total of 382 admission notes from March 2013 to December 2013 were retrospectively analyzed according to the requirement of ＂fundamental norms of medical record writing＂which issued in 2010.Results In these complete admission notes , there were problems in every part , including general information , chief complaint, history of present illness , the physical examination , assistant examination and primary diagnosis .The most problem was history of present illness accounted for 36.1% .The least problem was assistant examination accounted for 4.2%.Conclusions There were many problems of admission note written by interns in respiratory medicine department .We should strengthen legal education , improve interns professional ability and quality , enhance our teachers clinical teaching consciousness , which is very important for improving writing quality of the admission note of interns .