病案书写中的缺陷及对策

Delects in Medical Records Writing and Countermeasures

目的探讨医院病案书写规范化管理的对策;方法分析病案中的缺陷及原因;结果病案质量在完整性和规范性等方面存在缺陷,这与工作量大、危重患者较多等原因有关。同时,也与医务人员对病案质量重视不够和监管力度不够有关;结论加强质量教育和管理力度以提高病案质量。

Objective To investigate the countermeasures of standardized managementZ of the medical records. Methods Tile defects and reasons of medical records were analyzed. Results Defects appeared in the integrity and standardization of medical records which associated with heavy workload and too much critical iii patients. Meanwhile, medical staffs paid less attention to medical records quality and inadequate supervision also contributed to this phenomenon. Conclusion Education quality and management intensity should be strengthened to improve tile medical records quality.