| 健康体检报告与病历书写基本规范 |
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| 引用本文： | 胡燕生,梁金凤,李斌. 健康体检报告与病历书写基本规范[J]. 中国病案, 2011, 12(2): 4-5 |
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| 作者姓名： | 胡燕生 梁金凤 李斌 |
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| 作者单位： | 首都医科大学附属北京朝阳医院,北京市,100020 |
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| 摘 要： | 健康体检报告的书写质量须遵照卫生部病历书写基本规范,设计符合不同类型查体的表格,完善基本项目和内容,规范检查、检验报告及体检结论等,实现信息共享。确保健康体检记录和结论客观、准确、规范。
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| 关 键 词： | 健康体检报告 书写质量 信息共享 |
Basic Norms of Physical Examination Report and Medical Records |
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| Hu Yansheng,Liang Jinfeng,Li Bin. Basic Norms of Physical Examination Report and Medical Records[J]. Chinese Medical Record, 2011, 12(2): 4-5 |
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| Authors: | Hu Yansheng Liang Jinfeng Li Bin |
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| Affiliation: | Hu Yansheng,Liang Jinfeng,Li Bin,Beijing Chaoyang Hospital of Affiliated,Capital Medical University,Beijing 100020,China |
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| Abstract: | The writing of physical examination report needs to compliance with basic norms of medical records,the basic items and contents can be improved and inspection reports and physical examination conclusions can be standardized by designing different types of health check forms,then the sharing of information can be realized.The objectiveness,preciseness and criterion of physical examination records and conclusions should be guaranteed. |
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| Keywords: | Physical examination report Writing quality Information Sharing |
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