书写病历是我们临床医师每天上班必须做的事情,提高病历质量也是我们耳边不断听到的话。我们不能等到发生医疗纠纷时才想到我们当时怎么没有认真按照规范书写病历,以致存在那么多隐患却已无补救的可能了。原因就在于有的医师认为重要的是提高自己的医疗水平,忽视了病历书写规范的重要性。在日益增多的医疗纠纷中,因为病历的问题使 Writing medical records is something clinicians must do when they go to work every day. Improving the quality of medical records is what we hear constantly. We can not wait until the medical dispute arises to think of how we did not seriously write medical records according to the norms so that there are so many hidden dangers that no remedy is possible. The reason is that some doctors think it is important to improve their medical standards, ignoring the importance of writing medical records specification. In the growing number of medical disputes, because of the medical record problem