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病案是医师对疾病作出诊断,采取治疗措施,护理人员进行护理等临床实践的原始记录。病案质量集中反映一所医院的基础医疗质量和医疗水平,临床医师医疗业务水平和业务素质。病案质量管理是全面医疗质量管理的基础,提高医疗质量必须从病案质量管理抓起。一、加强病案书写质量病案质量是评审医疗质量的重要依据。因此,病案书写内容必须真实、可靠、完整、及时、准确。尤其是反映疾病特点及转归的一些重要内容,诊断及鉴别诊断依据,特殊检查结果,应进行有层次的记载。“现病史”应完整,“体格检查”应准确,“首次病程记录”应逻辑性强,
Medical record is a doctor’s diagnosis of the disease, to take treatment measures, nursing staff to carry out the original records of clinical practice. The quality of the medical record reflects the basic medical quality and medical level of a hospital, the level of medical service and the professional quality of the clinician. Medical records quality management is the basis of a comprehensive medical quality management, medical quality improvement must start from the medical record quality management. First, to strengthen the quality of medical records The quality of medical records is an important basis for evaluation of medical quality. Therefore, the contents of the medical records must be true, reliable, complete, timely and accurate. In particular, reflect the characteristics of the disease and the outcome of some of the important elements of diagnosis and differential diagnosis based on the results of special inspections should be carried out at different levels. “History of Illness ” should be complete, “Physical examination ” should be accurate, “The first course record ” should be logically strong,