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书写病历是每个医师的职责。书写病历就要掌握书写病历的要点。本文中的要点就是作者44年工作的总结及近七年质控工作中发现的一些问题和书写病历需掌握的要点总结如下。1病历书写要掌握的要点1.1精辟和正确表达主诉主诉是患者就诊时的主要症状或体征和发病期限。症状或体征在?
Writing a medical record is the responsibility of every physician. Writing a medical record requires grasping the key points of writing a medical record. The main points in this article are the summary of the author’s work in 44 years and the problems found in the quality control work in the past seven years and the points that need to be mastered in writing medical records are summarized below. 1 Points to be grasped in the writing of medical records 1.1 Incisive and correct expression The chief complaint is the main symptoms or signs and the time limit for the onset of illness. Symptoms or signs in?