认真书写病案培养良好的行医习惯

Careful Writing of Medical Records for Training Well Habit of Practice Medicine

文章分析了病案书写过程中存在的问题,如住院病案首页填写不全、入院记录内容简单、术前讨论不完整、手术记录书写不及时等。并就其原因进行了讨论,主要是重视程度不够、法律意识淡漠等。提出应通过强化法律意识,提高认真书写病案的自觉性,激发病案书写的内生动力以及建立激励机制,促进医师通过病案的书写建立起缜密的临床思维,形成一种终身不改的良好行医习惯。

The article analyzes the existing problems during medical records writing,such as incomplete filling of front page in hospitalization medical records,simple content of admission record,incomplete of discussion before surgery and not timely writing of surgery record and etc.It discusses reasons of it which are mainly not enough value and weak law consciousness.This article puts forward that we should strengthen consciousness of law and careful writing medical records,stimulate internal motivation of medical records writing,set up encouragement mechanism and promote careful clinical thought of doctors through medical records writing in order to form a well habit of practice medicine for long-life.