放射治疗科住院医师病历书写规范化培训的管理措施

Management Measures of Medical Records Writing Training for Resident Doctors in Department of Radiation Oncology

放射治疗是恶性肿瘤的重要治疗手段之一,放射治疗科的病历书写既要体现恶性肿瘤的疾病特点及诊治过程,还应详实、清晰地记录放射治疗计划及治疗过程,因此,病历书写是放射治疗科住院医师培训的重要组成部分。本文详细阐述病历书写培训中的教学内容,结合学科特点,从恶性肿瘤及放射治疗专业知识两方面归纳总结病历书写的主要内容、要求及质控原则,并强调病历质量管理的重要性,提出改善病历书写质量的有效方法。

Radiotherapy is one of the therapeutic methods ior malignant tumors, lvlealcm recorus wnung m Department of Radiation Oncology should not only embody the characteristics of malignant tumor and the process of treatment, but also record down the treatment plan and therapeutic process of radiotherapy detailed and authentic. Therefore, medical records are important materials during the course of residents train in malignant tumors. Our article elaborated the content of medical records writing training, and summarized the primary coverage, requirement and principles of medical records writing. It also emphasized the importance of medical record quality management, and presented several feasible ways to improve medical record quality.