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病历又称病案,是医务人员记录疾病诊疗过程的文件。它完整地、客观地.连续地记录了病人住院期间的病情变化和诊疗过程。可以认为,它是分析研究、考核医务人员,评定医疗质量及工作效率的依据。近几年,我们结合年终工作考核,发现医院病历质量差,资料不齐全等问题,遂采取一系列可行的改进措施,逐步提高临床医师病历的书写技能,加强医案管理,并已初见效果。现将900份住院病例质量情况分析综述如下。
The medical record, also known as the medical record, is a document for medical personnel to record the disease diagnosis and treatment process. It completely and objectively records the patient’s change of condition during hospitalization and the process of diagnosis and treatment. It can be considered that it is the basis for the analysis, research, assessment of medical personnel, and assessment of medical quality and work efficiency. In recent years, combined with year-end job evaluations, we have found that hospital medical records are of poor quality and incomplete information. We have adopted a series of feasible improvement measures to gradually improve the writing skills of clinical doctors’ medical records, and to strengthen medical record management, and have seen initial results. . The quality analysis of 900 inpatients is summarized below.