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目的规范病历书写,加强病历管理质量,提高医师书写病历质量。方法以《陕西省病历书写规范》要求为蓝本,结合病历书写的缺陷,将《陕西省病历书写规范》的文字整理为《病历、首页书写规范及要求参照用表》。结合本表在我院的应用,使病历书写质量明显提高。结论达到病历质量的预期效果。
Objective To standardize the writing of medical records, strengthen the quality of medical record management and improve the quality of physicians’ writing of medical records. Methods Based on the requirement of “Medical Records Writing Standard in Shaanxi Province”, combining the defects of medical records writing, the text of “Medical Records Writing Standard in Shaanxi Province” was organized into “Medical Records, Home Writing Norms and Requirements Reference Tables”. Combined with the application of this form in our hospital, the quality of medical records is obviously improved. Conclusion The expected result of the medical record quality is reached.