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医院改革的目的是提高医疗质量。医疗质量涉及整个医院的质量管理、病历、诊断、治疗、抢救、护理、营养等方面,关系到每个医护人员的素质、职业道德和业务水平。 病历为检查医疗质量重要依据之一,评价以往病历只能从字迹是否清楚、内容是否完整及逻辑性如何来判断。然而,高的医疗质量并不一定与面面具到的病历相一致。因此,我认为对照现症病人来检查病历则是相当重要的。主任、主治医师定期查房时能否及时对下级医师病历进行严格的检查,并加以修改是提高医疗质量的关键。
The purpose of hospital reform is to improve the quality of medical care. The quality of medical care involves the entire hospital’s quality management, medical records, diagnosis, treatment, salvage, nursing, nutrition, etc., related to the quality of each medical staff, professional ethics and business standards. The medical record is one of the important basis for checking the medical quality. The evaluation of past medical records can only be judged by whether the handwriting is clear, whether the content is complete and how logical it is. However, high medical quality does not necessarily coincide with the medical records of facial masks. Therefore, I think it is very important to check the medical records against the current patients. The director and the attending physician can check the medical records of the lower-level doctors in a timely manner while checking the room regularly, and modification is the key to improving the medical quality.