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目的 提高病案书写质量。方法 通过分析比较纸张病历与电子病历书写质量存在的问题和原因,找出解决方法和对策。结果 病案质量在形成过程中得到有效控制。结论 为适应新形式的发展,应加强病案质量的管理,强化书写证据意识,从而保护医患双方的合法权益。
Objective To improve the quality of medical record writing. Methods By analyzing the paper medical records and electronic medical record writing problems and causes, find solutions and countermeasures. Results The quality of medical records was effectively controlled in the process of its formation. Conclusion In order to adapt to the development of new forms, the quality of medical records should be strengthened and the written evidence should be strengthened so as to protect the legitimate rights and interests of both doctors and patients.