实习医师病历书写存在的问题及解决方法

Thinking much of the Ability of Documentation of the Medical Record of the Interns

病案书写是重要的临床基本功之一,但由于目前的临床实习普遍只重视临床诊疗技能的培训,导致实习医生书写的病案存在不少问题,既影响医院总体病案质量,也不利于将来的临床工作。因此有必要转变观念,加强实习医生病案书写能力锻炼,使得他们走上工作岗位后能重视病案书写质量和内涵质量,切实做好自我保护。

The documentation of the medical record is one of the basic training for the interns, however, there are a lot of problems in the documentation of the medical record for the interns because only the skills of diagnosing and treating are generally emphasized, which influenced the quality of the medical record and the future clinical work of them as well. Therefore, it is necessary for us to change the idea to stress the training of the documentation of the medical record of the interns, making them thinking much of the documentation and connotation of the medical record when they work as a doctor in hospitals, and keeping themselves from the harms caused by poor documentation of the medical record.