基层中医病案书写存在的问题与对策分析

Problems and Countermeasures in the Writing of Medical Record in the Basic Level

病案是中医用来记录病人疾病的发生、疾病的发展、疾病的诊断、疾病的治疗以及疾病的预后等方面的资料档案,它是具有法律效应的,在解决医疗纠纷、医疗保险赔偿等方面有着重要的作用。病案的品质可以直接反映一个医疗单位的工作水平和作风,笔者通过对一些基层中医病案的调查,发现了基层中医病案书写存在的问题。该研究首先提出病案书写的基本要求,以及基层中医病案书写存在的问题,其次分析基层中医病案书写问题的原因并给出合理的建议和意见。

Medical record is a traditional Chinese medicine to record the occurrence of disease, the development of disease, disease diagnosis, treatment and prognosis of the disease, it is a legal effect, in the settlement of medical disputes,medical insurance compensation, etc.. The quality of medical record can directly reflect the work level and style of a medical unit. The author finds out the problems in the writing of basic medical records by investigating some basic medical records. This paper first puts forward the basic requirements of medical record writing, as well as the problems in the writing of basic medical records, and then analyzes the reasons for writing the problem of basic medical records and gives reasonable suggestions and opinions.