如何书写好内科病历

病历是医疗活动的原始记录或历史记载,是最准确,可信的记录。在现代医院管理中,病历作为医疗活动信息的主要载体,不仅是医疗、教学、科研的第一手资料,而且也是综合评价医院医疗质量、技术水平、管理水平的依据。即病历质量好坏体现医生的学术和品德,体现医院的管理水平和医疗质量。病志书写的水平,是一位医生理论基础、技术水平、临床经验、表达能力、逻辑思维的综合检验。然而现在有些病历,特别是大医院的病历质量不高的原因是工作太忙,病人太多。下级医师对疾病特点了解不够,概念不清楚。上级医师要养成习惯把您心里想的思路说出来,以提问的方式讲更好,这样对下级医生的印象会更深,同时也可以掌握他们是否理解正确了,督促下级医生平时的学习,始终要抓"三基三严",强调临床基本功。本文把内科病历书写中的常见问题一一列出,并具体指导如何改进。

How to Write a Medical Record

Medical record is the original record of the disease course and treatment process, including logic consideration of the physician in diagnosis and treatment of the disease. It represents academic foundation, technical level, clinical experience and the technique of expression of the physician. It is the first data for medical management, teaching and researching work. In recent years, physicians are very busy, especially in large hospitals. The level of medical record, written by junior physicians, without enough fundamental knowledge, is usually quite unsatisfactory. They need senior physicians＇ instruction. The senior physicians should better first ask what young physicians think and then the teachers would express their own way of thinking and emphasize the fundamental knowledge and technique.