住院病案表达形式及其内容的思考

Thinking of The style of The History Expression for In-ward patients and Its Components

本文分析了当前住院病案存在着表达形式单一、书写内容重复和内容形式化等问题，提出了在病案基本框架规范下，起始病史可采用多种表达形式；注重病程录内在质量；把护理记录作为病程录的组成部分，改医护文书记录“分体式”为“一体化”，丰富病案内容，提高病案质量等观点。

This paper analysed the nowadays existing problems of the in－ward patients historis:the expressing style being unitary,components being repeated and single in form and suggested that based on the foundamental standard frame of patient history the writing of patient history might be multiform in expression,paying attention to records of the disease course of internal quality connection,taking the nursing records as component parts of the records of the disease course. In doing so, the existing problems of writing a patient history for medical workers could be 'unified' instead of 'a style of separated and unrelated one'enrich the contents and raise the quality of patients'histories.