病案不仅是患者疾病发生、发展、诊断、治疗的客观记录,也是医疗质量、医疗水平及管理水平的综合反映。从2003年2月开始,我院采取全程监控、重点强化的办法加强了门诊病历书写质量管理,但在工作中仍然有不合格病案出现,既影响了患者的就医质量,也给医院带来了不好的影响[1]。为 The medical record is not only an objective record of the occurrence, development, diagnosis, and treatment of the patient’s disease, but also a comprehensive reflection of the medical quality, medical level and management level. Since February 2003, our hospital has taken steps to monitor and strengthen the management of medical records in outpatients. However, there are still unqualified medical records in the work. This not only affects the quality of the patient’s medical care, but also brings about the hospital. Bad influence [1]. for