简化住院病历书写的必要性及改进建议

The Feasibility and Countermeasures of Simplifying Hospital Medical Record Writing

目的探讨和评估简化病历书写的必要性与适用性,为完善病历管理规范提供依据。方法对全国91所三级医疗机构3779医护人员进行问卷调查,了解医务人员对目前病历书写繁简程度的认识及简化病历书写的意见。结果现实病历书写耗时普遍超出期许,简化病历书写应保留强化核心内容,剥离非诊疗需要的书写。结论简化病历书写具有必要性、可行性,应从制度规范上予以改进。

Objective Discussion and evaluation the feasibility and applicability of simplified medical record writing, provide basis for further revision. Method 3779 medical staff from 91 medical institutions were investigated. Questionnaire were used to understand opinions of medical staffs on the actuality of medical record writing and tendency for the simplifing. Result Medical record writing tim^consuming situation general beyond expectations of the medical staff. To simplify the medical record writing should keep strengthening the core content, stripping writings without diagnosis and treatment need. Conclusion The simplifying of medical record has the necessity and feasibility in our country. The system should be reform.