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对照规范化管理前后我院病历书写的情况。方法调取我院2003年11月、12月、2004年1月及2005年11月、12月及2006年1月病案进行对照分析,从中各取100份病案进行病历书写分析。结论规范化管理后我院病历书写质量提高了50%。结果我院病历书写还需要加强管理监督,制定具体要求,落实具体检查措施。
Comparison of standardized medical records before and after management in our hospital. Methods A control analysis of the medical records of our hospital in November, December, January, 2004 and January, December, and January of 2005 was carried out for comparison and analysis. 100 medical records were taken from each of them for medical records analysis. Conclusion The quality of medical records in our hospital has been improved by 50% after standardized management. Results The writing of medical records in our hospital needs to strengthen management supervision, formulate specific requirements, and implement specific inspection measures.