摘要
目的提高医师的病历书写质量,保障医疗安全,规避医患纠纷。方法通过讲授病案书写要求,相关的法律法规和规章制度,分析病历书写存在的缺陷,有针对性地开展病历书写规范化培训。结果增强了医师对病历规范化书写的重要性的认识,完善了他们在病历规范化书写方面及相关规章制度和法规方面存在的知识缺陷,提高了病历书写的基本技能。结论病历书写规范化培训是有效和必要的。
Objective To improve the writing quality of medical records,ensure medical safety,and evade medical disputes.Methods Carry out a standardized training of medical records by teaching medical record writing requirement,relevant lans,regulations rules and analyzing the defects of medical records.Results Enhance the consciousness of standardized training of medical records,and improve the base technique of writing of medical records.Conclusion Standardized training of medical records is effective and necessary.
出处
《中国病案》
2011年第4期12-13,共2页
Chinese Medical Record
关键词
病历
规范化培训
Medical records
Standardized training
