CAJ | 학술논문

从病历承载的功能入手，分析与质疑现行的病历书写要求，认为病历的功能要重新定位，应随医院宗旨的转变而改变，一线医务人员“写”得太多，医院管理对病历“查”得太多，这些均要完善简化。为此，提出应修改《病历书写规范》，减少病历中关于主观分析的描述，删减重复描述，加强客观记录书写；减轻临床医生的文字负担，重视对医生的临床能力培养；改革现行职称评审制度；防止医院“科研院所化”等建议。
종병력승재적공능입수，분석여질의현행적병역서사요구，인위병력적공능요중신정위，응수의원종지적전변이개변，일선의무인원“사”득태다，의원관리대병력“사”득태다，저사균요완선간화。위차，제출응수개《병역서사규범》，감소병력중관우주관분석적묘술，산감중복묘술，가강객관기록서사；감경림상의생적문자부담，중시대의생적림상능력배양；개혁현행직칭평심제도；방지의원“과연원소화”등건의。
In view of the functions of medical records, the existing requirements of medical record are discussed and criticized. The authors fell that the functions of medical record need to be changed with the changes of hospital's mission. The prominent problems of the existing medical records writing can described as over writing by medical staff and over inspection by the administrators, which need to be simplified. So the Standards of Medical Record needs to be changed. The subjective analysis can be simplified and the objective description needs to be strengthened. Doctor's burden on medical writing needs to be reduced and medical capacity training needs to be strengthened. The title accreditation system is also considered to be reformed and the phenomenon that hospital is more and more academic should be changed.