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病案是医疗档案的重要组成部分,它不仅记载着病人住院期间的整个病情变化及治疗护理的全过程,而且其法律和凭证的作用,已越来越受到人们的重视。因此提高病案的书写质量对医院的医疗、教学、科研等都有着重要的意义,我们通过工作实践并结合医院实际,采取了一系列提高病案书写质量的措施,收到了比较满意的效果。 一、建立标准:参照《江苏省病历书写规范》、《江苏省住院病历质量评价标准》,分别制订了我院
The medical record is an important part of the medical file. It not only records the entire change of the patient’s condition during hospitalization and the whole process of treatment and care, but also the role of its laws and vouchers has attracted more and more attention. Therefore, improving the writing quality of medical records has important implications for the hospital’s medical treatment, teaching, and scientific research. We have adopted a series of measures to improve the writing quality of medical records through work practices and in combination with the actual conditions of hospitals. We have received satisfactory results. First, the establishment of standards: refer to “Jiangsu Province medical records writing standards”, “Jiangsu Province hospital records quality evaluation criteria”, respectively, the establishment of our hospital