门诊病历是提高门诊工作质量的重要环节,下面结合临床实践谈谈这方面的体会。 1.目前普遍存在的主要问题:(1) 姓名、性别、年龄、病历号、就诊日期、地址等一般项目填写不全;(2) 病历简单,缺乏必要的体检记录;(3) 诊断依据不足,或误诊,漏诊。产生以上问题的原因是:(1) 某些医师对门诊工作及门诊病历的书写在思想上不够重视。认为门诊工作是临时性的,工作简单(医生调动频繁),门诊病人多,没有时间按要求、规则写病历;(2) 对门诊病历基本功缺乏锻炼,以及对门诊常 Outpatient medical records are an important part of improving the quality of outpatient work. The following experiences are combined with clinical practice. 1. The main problems that currently prevail: (1) Incompleteness of general items such as name, gender, age, medical record number, date of visit, address, etc.; (2) simple medical records and lack of necessary medical records; (3) inadequate diagnostic basis. Or misdiagnosis, missed diagnosis. The reasons for the above problems are: (1) Some doctors do not pay enough attention to the writing of outpatient work and outpatient medical records. It is considered that outpatient work is temporary, the work is simple (frequent doctors mobilization), there are many outpatients, and there is no time to write medical records according to requirements and rules; (2) The lack of exercise in the basic skills of outpatient medical records, as well as outpatient consultation