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病历书写是临床工作的重要部分,其质量反映了医院医疗与管理水平。作者参照《湖南省病历书写规范和病案(例)医疗质量评定标准》,对近二年该院终末质控的539份病案中常见缺陷作了分析总结。体会到抓好环节质控;落实三级查房;加强业务学
Writing medical records is an important part of clinical work, and its quality reflects the hospital medical and management level. The author has analyzed and summarized the common defects in the 539 medical records of the hospital’s final quality control in the past two years referring to the “Human Medical Record Writing Standards and Medical Records Quality Assessment Standards”. Experience the quality control of the link; implement the third-level rounds; strengthen the business