摘要
主任查房记录质量缺陷的主要原因表现为查房准备不够充分,记录流于形式,无针对性。应以抓疑难病例、危重病人、新入院及疗效不佳的病例为重点。查房内容要抓住诊断及时准确,治疗符合原则,措施合理恰当,对病情的分析思路是否条理清晰,记录是否完整及时、更改的医嘱、制定的治疗方案及需要的检查项目是否落实到位为基本内涵。
The main reasons for writing a bed director ward inspection record are inadequate preparation, and a mere formality and untargeted record. Appropriate corrective edvices were improved such as to focus on intractable case, critically ill patients, new hospitalized cases and poor curative effect. To improve the quality by ways of seizing the timely and accurate diagnosis, treatment in line with the principle, reasonable and appropriate measures, and good curative effect.
出处
《中国病案》
2013年第1期42-42,共1页
Chinese Medical Record
关键词
病历书写
主任查房记录
改进措施
质量管理
Medical record writing
Director ward inspection record
Improvement measure
Quality management
