摘要
《病历书写基本规范》在原试行版经过为期7年多的实践的基础上得到了进一步的完善,并于2010年3月1日起正式施行。与试行版相比,新的《病历书写基本规范》彰显出7大特点,但在对文书记录者身份的要求、实习医务人员及试用期医务人员书写病历内容范围、前后用词的统一性等方面仍值得商榷。对此提出建议:明确每一种文书记录者的身份或资格;用词规范并前后统一;高度重视医嘱管理。
The Basic Standard of Documentation of the Medical Record （on trial） has further completion after 7 years of practice, and will be implemented formally from March 1st ,2010. Compared with the trial edition, the new edition highlights seven characteristics, but there are some debates on the requirements of recorder’s identity, the authority of medical document between internship medical personnel and medical personnel in probationary period, and the unity of words, etc. The suggestions are made as follow：each recorder’s identity or qualifications should be clear;the standardization and the cohesion of the words should be ensured;and the medical order management should be paid highly attention.
出处
《中国医院管理》
2010年第7期6-8,共3页
Chinese Hospital Management
关键词
病历
病历记录
规范
medical record
documentation of the medical record
standard
