最近,笔者参加内江地区对县医院工作的检查,发现病历上存在不少问题。我们用随机抽样方式,在4个县医院提取各科病历近200份,进行查阅,座谈,发现对病历的书写、管理上存在以下问题。一、病历质量普遍较差。主要是医生对病历的重要性认识不足,缺乏责任感,不愿多花时间、精力。书写简单、潦草,应付了事,不能 Recently, I participated in the examination of the county hospitals in Neijiang and found that there are many problems in the medical records. We used a random sampling method to collect nearly 200 medical records from each of the four county hospitals for review and discussion. We found that the following problems existed in the writing and management of medical records. First, the quality of medical records is generally poor. The main reason is that doctors lack understanding of the importance of medical records, lack of sense of responsibility, and do not want to spend more time and energy. Write simple, scrawl, cope, cannot