住院病人外出病历书写的调查与分析

Survey and Analysis on Medical Records Writing of Inpatients' Egress

目的探讨病人住院期间关于外出正确的书写方法。方法自行设计调查问卷内容,直接发放调查表到各临床科室,由医师、护士如实填写,收集后进行汇总,综合分析,同时抽查住院当中外出病人的病历书写情况。结果医护人员对病人外出,医疗、护理文件书写存在举证无能的现象,因而引起我们密切关注,提出正确的书写病历方法。

Objective To discuss the right writing method of medical records about inpatients＇ egress. Methods Doctors and nurses in all clinical departments were surveyed by self- designed questionnaire. And the medical records writing about inpatients＇ egress was examined selectively among them. Results Medical staffs can＇t adduce evidence in medical records writing about inpatients＇ egress, which should be paid attention. And the right writing method of medical records should be brought forward.