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病案是医院管理中的重要信息资料,是监督医院医疗工作,进行科学管理的可靠根据。病案的真实和完整与否,标志着一个医院工作人员的服务态度和医疗业务水平,同时也反映了临床医师的业务素质。笔者试图通过330份住院病案的分析,探讨近二年来职工医院病案的质量和问题以及解决的对策。
The medical record is an important information material in hospital management and is a reliable basis for supervising hospital medical work and scientific management. The truthfulness and completeness of the medical record indicate the service attitude and medical service level of a hospital staff member, and also reflect the professional quality of clinicians. The author tries to analyze the quality and problems of staff medical records in the past two years and the countermeasures to solve them through the analysis of 330 inpatient medical records.