实习医师病历书写的现状与措施

Status and Countermeasures of Medical Record Written by Intern

病历书写可拓宽实习医师的临床视野,培养临床思维能力,提高医疗综合素质。但随着公众法律及维权意识的增强、《医疗事故处理条例》的出台和医疗纠纷的日益增多,病历质量越来越重要,实习医师病历书写标准也越来越高。本文对当前实习医师书写病历存在的问题进行分析探讨,并提出应对措施。

Writing medical records could broaden the vision of interns,cultivate their ability of clinical thinking and improve their comprehensive quality of health care.However,with the increasing public awareness of law and human rights,the increasing of medical disputes and the introduction of the Regulations on the Handing of Medical Accidents,the quality of the medical records has become much important,which also require the higher standard of the medical record written by interns.The article analyzed the problems that exist in the present documentation of the medical record of the interns,and proposed some countermeasures.