| 病历书写中的质量缺陷 |
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| 引用本文： | 孟红旗,朱凡特. 病历书写中的质量缺陷[J]. 医学与哲学(人文社会医学版), 2010, 0(4): 70-71,80 |
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| 作者姓名： | 孟红旗 朱凡特 |
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| 作者单位： | 广东佛山科学技术学院医学院医学系,广东佛山528000 |
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| 摘 要： | 病历书写中的质量缺陷存在于主诉、病史、体格检查、病程记录、诊断等各个方面。提高医学生病历书写质量及临床思维能力,是完成高质量病历书写的关键。同时病历书写有关的法律、法规相继出台,对病历书写提出了新的挑战。
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| 关 键 词： | 病历书写 质量缺陷 法律意识 |
Quality Defects in Medical Records Written |
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| Affiliation: | MENG Hong-qi , ZHUN Fan-te. (Department of Clinical Medical, Foshan University, Foshan 528000, China) |
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| Abstract: | Quality defects of medical records written existed in other aspects of chief complaint, medical history, physical examination, course records and diagnosis. Improving medical writing quality and clinical thinking ability of medical students was a key of high-quality medical records. At the same time, the law regulations relating to medical records were introduced. It has brought new challenges in medical records. |
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| Keywords: | medical records written quality defects legal awareness |
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