住院病历抽查存在的问题分析
[摘要] 目的 促进临床提高病历书写质量和服务水平，保障病历的法律证明效应。方法 随机抽取笔者所在医院3月份病历150份，按《病历书写基本规范》和相关文献资料进行分析点评。结果 病历存在书写不规范、项目缺失、未按规定书写通用名、围手术期用药不规范等问题。结论 加强病历质量监控力度和相关知识培训，才能保证住院病历终末质量，避免病历成为医院举证不能的现象。
[关键词] 病例书写规范；病例归档
[中图分类号] R197.3 [文献标识码] C [文章编号] 2095-0616(2011)08-150-02
Analysis of Problems in Sampling Medical Records
LIU Juan
The People's Hospital of Chibi in Hubei Province，Chibi 437300，China
[Abstract] Objective To improve the medical records for clinical quality and service levels and to protect the legal proof of medical effect. Methods Randomly selected 150 medical records of our hospital in March ......
您现在查看是摘要页，全文长 4313 字符。
[关键词] 病例书写规范；病例归档
[中图分类号] R197.3 [文献标识码] C [文章编号] 2095-0616(2011)08-150-02
Analysis of Problems in Sampling Medical Records
LIU Juan
The People's Hospital of Chibi in Hubei Province，Chibi 437300，China
[Abstract] Objective To improve the medical records for clinical quality and service levels and to protect the legal proof of medical effect. Methods Randomly selected 150 medical records of our hospital in March ......
您现在查看是摘要页，全文长 4313 字符。