基层医师非规范化书写病历的常见原因及防范

Analysis on Causes for Irregular Medical Records of Primary Physicians and Prevention

目的通过对基层医院病历书写的现状进行分析,从病案管理的角度加以控制及防范医疗纠纷,有效提高医疗质量,保障医疗安全。方法对考核病历中存在的书写问题进行归纳总结,找出常见问题及解决方法。结果加强病案质量监控对防范医疗纠纷切实可行。结论加强基层医院医师病历的质量管理,完善《病历书写基本规范》,可以有效防范医疗纠纷。

Objective Through analyzing the writing status of medical records in primary hospital,medical disputes were controlled and prevented in terms of medical records management to improve medical quality effectively and ensure medical safety.Methods Defects existing in the writing of checked medical records were summarized to find common problems and raise countermeasures.Results The prevention of medical disputes was feasible.Conclusion The quality management of medical records of primary physicians is enhanced,and the Basic Regulation of Case Handwriting should also be improved,which can prevent medical disputes effectively.