1病案首页检查情况全国《住院病历书写质量评估标准》的出台,标志着住院病案有了新的质量评估标准,是病案管理走向签字不清无记录日期缺家族史个人史有误病人一般身份情况不确切实习医师代替住院医师写入院记录入院诊断欠全面合计缺陷项目数量11211219%5510551054520份入院记录 1 medical records Home check the national “hospital medical record writing evaluation criteria for quality” promulgated, marking the hospital with a new medical assessment of the quality standards for medical records management is not clear no record date missing family history of personal history of the wrong patients general status Inaccurate Intern replaces Resident Write Inpatient Record Inpatient Diagnosis Under-Total Total Defects Number of Items 11211219% 5510551054520 Admission Record