病案是医疗、教学、科研、法律工作的重要资料,病案质量是医疗质量的重要体现。如何提高病案质量是一项困难而艰巨的任务,不少医院成立了病案质量检查组,对于提高病案质量起到了积极推动作用。笔者认为,临床医师是病案资料的书写者又是主要使用者,因此,狠抓各级医师对病案的正确书写,对于提高病案质量起着根本作用。 Medical records are important data for medical treatment, teaching, scientific research and legal work. The quality of medical records is an important manifestation of medical quality. How to improve the quality of medical records is a difficult and arduous task. Many hospitals set up a medical record inspection team to play an active role in promoting the quality of medical records. The author believes that clinicians are the writer and the main user of medical record data. Therefore, paying close attention to the correct writing of medical records by doctors at all levels plays a fundamental role in improving the quality of medical records.