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随着改革开放的深入,广大群众的自我保健意识不断增强,医院住院病人逐渐增多。病案记录的规范、完整、详细、准确对住院病人诊治预后判断及国际疾病分类具有重要意义,也是处理医疗纠纷的法律凭证。我院按《福建省病历书写规范》,对2004年1-6月的出院病案进行随机抽样调查,以便?
With the deepening of reform and opening up, the general public’s awareness of self-care has been continuously enhanced, and hospital inpatients have gradually increased. The standardized, complete, detailed and accurate record of medical records is of great significance for the diagnosis and prognosis of inpatients and international disease classification, and is also the legal evidence for handling medical disputes. According to the “Code for the Writing of Medical Records in Fujian Province” in our hospital, a random sample survey was conducted on the hospital discharge cases from January to June 2004 so as to