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病历是反映病人病情的全程记录,其中现病史是病历的核心部分,决定着病历的内涵和质量,体现着医师的敬业精神,具有重要的法律凭证作用。然而当前病历的现病史的书写质量令人堪忧,部分医生由于不认真或经验不足等原因,所写的现病史经常不能抓住书写要点,出现各种错误,如现病史与主诉脱节,文字描述错误等书写问题颇为普遍。临床医生应尽量避免出现现病史书写过程中的常见问题,提高现病史书写质量是作出正确的诊断及制定正确的诊疗方案的基础。
Medical records reflect the full record of the patient’s condition, of which the current medical history is the core part of the medical record, which determines the connotation and quality of the medical records, which embodies the professional dedication of the physicians and plays an important role as a legal document. However, the current history of the current medical history of the writing quality is worrying, some doctors because of not being serious or inexperienced and other reasons, the written history of illness often can not grasp the main points of writing, there are various errors, such as the current illness history and the main complaint, the text description Wrong writing problems are quite common. Clinicians should try their best to avoid common problems in current history writing and improve the quality of current history writing is the basis for making correct diagnosis and formulating the correct diagnosis and treatment plan.