规范书写病历是职业医生的基本素养,经得起法律检验的文件在医疗纠纷时既保护患者也保护医生。及时、全面、准确的病历记录可以减少医患间的误会,更可以规避不必要的医疗纠纷。 The standardized written medical record is the basic literacy of a professional doctor. Documents that can withstand legal inspection protect both the patient and the doctor during medical disputes. Timely, comprehensive and accurate records of medical records can reduce the misunderstanding between doctors and patients, but also can avoid unnecessary medical disputes.