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目的:探讨医护病历书写中出现的常见问题,制定解决策略。方法:总结聊城市人民医院2006/2007年2 a间出院病历和运行病历质检情况。结果:常见问题是主诉与现病史不一致,既往病史项目缺失,病程记录不完整等,影响了病历在科研、医疗、教学等诸方面重要作用的发挥。结论:解决策略是加强病历书写规范和法律意识;拥有坚实的医学基础理论知识;加强责任心,改进工作作风;加强质控督查,与奖惩挂钩。
Objective: To discuss the common problems appearing in the writing of medical records and formulate solutions. Methods: Summary of Liaocheng People’s Hospital in 2006/2007 2 a discharge medical records and running medical records of the situation. Results: The common problems were the inconsistent appearance of the main complaint and the current medical history, the missing items of the past medical history, and the incomplete records of the medical records, which affected the important role of the medical records in scientific research, medical treatment and teaching. Conclusion: The solution strategy is to strengthen the medical record writing norms and legal awareness; have a solid knowledge of basic medical theory; to strengthen the sense of responsibility and improve work style; strengthen quality control inspection, and reward linked punishment.