CAJ | 학술논문

针对神经外科医师在病历书写过程出现分析问题片面、病历内涵缺乏、时限错误、内容缺项、复制黏贴错误等问题.通过强化住院医师“三基”训练,规范病历书写,突出主治医师的监管职能,加强病历质量“三级”监督、落实病历质量持续改进制度等系列措施,对规范诊疗行为,提高病历书写质量,提升病历内涵,取得了良好的效果.
침대신경외과의사재병역서사과정출현분석문제편면、병력내함결핍、시한착오、내용결항、복제점첩착오등문제.통과강화주원의사“삼기”훈련,규범병역서사,돌출주치의사적감관직능,가강병력질량“삼급”감독、락실병력질량지속개진제도등계렬조시,대규범진료행위,제고병역서사질량,제승병력내함,취득료량호적효과.
@@@@Some problems such as parsing problem one-sided ,lack of connotation , time limit error ,content missing items and copy error are common in medical records writing .We should strengthen three bases training of resident doctor ,make medical record standard ,highlight the regulatory functions of attending physician , strengthen three-level supervision of medical record quality and carry out the medical record quality continuous improvement system to improve the quality of medical record writing ,enhance the connotation of medical records .