摘要
病历是宝贵的医疗资料,也是客观的法律文书。病历书写是一项基本的临床技能。目前实习医师病历书写质量有所下降,可通过提高对病历重要性的认识、加强基础知识的学习、掌握病历书写规范等措施加强实习医师病历书写能力的培养。
The medical record is important information of medicine and law.The writing of the medical record is one of the basic clinical training.The quality of writing medical record in the interns is declined at present.Through improving understanding,strengthening studying,mastering standard and so on,it can strengthen the ability training of writing medical record in the Interns.
出处
《现代医院》
2011年第3期108-109,共2页
Modern Hospitals
关键词
医学教育
实习医师
病历
书写
Medical education
Intern
Medical record
Writing
