丙级病历的判定标准与实施

The standards to judge class C patient record and its implementation

介绍多年来使用“病历质量检查表”和“丙级病历标准及处罚”的经验,提出使用“病历质量检查表”和“丙级病历标准”存在的问题,“采用单项否决判定丙级病历方法”进行筛查补充“细查”的可取性。提出了一些从根本上解决病历书写质量问题的办法。

The article introduces the experience for many years in utilization of 'quality checklist for patient record ' and 'standards tojudge class C patient record and its punishment', it outlines the problems in utilization of 'quality checklist for patient record ' and 'standardsto judge class C patient record', it is prefer to use screening to complement 'scrutiny checking' through 'judging class C patient record by singleitem rejection'. It outlines several methods to solve the quality problems in writing patient record.