神经外科住院病历存在的问题和改进措施

Existing Problems and Improving Measures of Medical Records of Neurosurgery Department

针对神经外科医师在病历书写过程出现分析问题片面、病历内涵缺乏、时限错误、内容缺项、复制黏贴错误等问题。通过强化住院医师"三基"训练,规范病历书写,突出主治医师的监管职能,加强病历质量"三级"监督、落实病历质量持续改进制度等系列措施,对规范诊疗行为,提高病历书写质量,提升病历内涵,取得了良好的效果。

Some problems such as parsing problem one-sided, lack of connotation, time hmit error, content missing items and copy error are common in medical records writing. We should strengthen three bases training of resident doctor , make medical record standard, highlight the regulatory functions of attending physician, strengthen three-levd supervision of medical record quality and carry out the medical record quality continuous improvement system to improve the quality of medical record writing, enhance the connotation of medical records.