摘要
目的提高出院记录书写质量。方法对照《广东省病历书写规范》的要求检查某院的终末病案。结果出院记录中存在常见的问题有复制造成的错误、前后内容不一致,记录过于简单、过于繁琐等。结论为适应新形势的发展,必须提高出院记录书写质量,推广实施有个性化的出院记录。
Objective To improve writing quality of discharged note.Methods The final medical records of a hospital were checked based on the writing standard of medical records in Guangdong Province.Results The common problems in discharged note were as follows：errors due to duplication,inconsistent contents,too simple and complicated records.Conclusion In order to adapt to the development of new situation,we must improve the writing quality of discharged note and promote the implementation of individuated discharged note.
出处
《中国病案》
2010年第7期22-23,共2页
Chinese Medical Record
关键词
出院记录
书写质量
病案
Discharged note
Writing quality
Special feature
