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病案的质量是医院质量管理的重点,是医院的医疗护理质量、诊疗技术水平、医疗管理水平的综合反映,它可为医、教、研提供丰富的科学资料,它也能为医疗纠纷和保险索赔等提供可靠的法律依据。随着病案质量要求不断的提高,病案质量有所提高,但也有不少问题存在。1主诉要求写出促使患者来医院就诊的最难受,最痛苦的主要体征,症状及持续时间,一般在应围绕主要疾病描述,文字力求简明揭要,具有高度概括性,一般不超过20个字。主诉的描述要正确不能含糊其词,所列症状只要写最主要
The quality of medical records is the focus of the hospital quality management, is the comprehensive reflection of the hospital’s quality of medical care, the level of diagnosis and treatment technology, and the level of medical management. It can provide rich scientific information for medical, teaching and research. It can also provide medical disputes and insurance Claims and other reliable legal basis. With the continuous improvement of medical record quality requirements, medical record quality has been improved, but many problems still exist. 1 The main complaint is to write out the most uncomfortable and painful major signs, symptoms and durations that motivate the patient to come to the hospital. The general description should be based on the description of the major diseases, concisely and concisely, with a high degree of generality and generally no more than 20 words . The description of the main complaint should not be vague, the symptoms listed as long as the main write