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目的全面推行依法行医观念,尝试医院管理与卫生监督的有效结合,以减少病历书写缺陷,提升病历书写质量,规范医疗行为。方法对1家试点医疗机构病历书写规范进行卫生监督干预研究。结果医疗机构的病历书写不规范情况有所改善。结论病历书写不规范现象通过医院管理与卫生监督有效改善是一种有效尝试。
Objective To comprehensively promote the concept of practicing medicine in accordance with the law and try to effectively combine hospital management and health supervision so as to reduce the defects of medical records writing, improve the quality of medical records writing and standardize medical behaviors. Methods To conduct the health supervision and intervention research on medical record writing norms of a pilot medical institution. Results The non-standard records of medical records have been improved. Conclusion It is an effective attempt to improve the non-standard record of medical records effectively through hospital management and health supervision.