病案书写质量分析与对策

Analysis and Countermeasures on Medical Records Writing Quality

目的提高住院病案书写质量,使医院、医务人员、患者三方的权益得到法律保障。方法检查某医院2010年第一季度出院病人病案并进行分析。结果住院病案书写质量,与书写医师性别、职称、科室等因素有关。结论住院病案的书写仍然存在某些缺陷,需要采取多种对策,提高病案书写质量。

Objective To improve the medical record writing quality,and make sure the rights and interests of hospital,medical staff,and patients are guaranteed by law.Methods Check and analyze medical records of discharged patients in first quarter of 2010.Results The writing quality of medical record is relate to physician gender,job title,department and other factors.Conclusion There are still some shortcomings in medical record writing,various measures should be adopt to improve the writing quality of medical records.