病程记录是病人住院期间病情演变经过和诊治过程的记录。要求实事求是地、准确详尽地、重点突出的记录病情变化,治疗措施和效果。按照山西省卫生厅“医院文书规范”要求,除眉栏项目、时限等一般项目按“规范”书写外,我们将记录内容列出十条标准,进行书写质量评定,从而促进了病案书写质量,医疗理论水平,医疗质量的提高。 The course record is a record of the evolution of the patient’s condition during hospitalization and the diagnosis and treatment process. Requires realistic, accurate, detailed, and focused records of disease changes, treatment measures, and results. According to the Shanxi Provincial Department of Health’s “Hospital Instrument Norms” requirement, except for general items such as eyebrow hurdles projects and time limits written according to “standards”, we will list ten criteria in the records and conduct quality assessments of writings, thereby promoting the quality of medical record writing and medical services. Theoretical level, improvement of medical quality.