摘要
病历书写中的时间概念是体现诊疗过程的关键因素之一。常见时间记录缺陷包括重要时间记录不清,疏漏应有的时间记录,不注意时间记录的及时性与准确性,同一病情或诊疗措施的时间记录前后不一致,以及时间自我保护意识不强等5个方面。医政管理、药事管理、医院感染管理、仪器设备管理以及信息管理等部门应重视时间管理环节的监控工作。
The concept of time in medical record is one of key factors which embody the process of diagnosis and treatment. The common defects of time record include the important time not clear, careless omissions of necessary time record, lack of time- liness and exactness, disparity in time record for the same patient＇s condition or measures of diagnosis and treatment in front and at the back of medical record, and the dim self - protection mentality of time. The focal point of time control should be to carry weight for the department of medical affairs, pharmacy management, hospital infection control, equipment control and information system management for each medical establishment.
出处
《中国卫生质量管理》
2009年第6期34-36,共3页
Chinese Health Quality Management
关键词
病历
时间
时限
Medical Record
Time
Time Limit
