摘要
认为新版《病历书写基本规范》在病程记录这一部分的不足之处有:对病程记录的界定欠妥;只要求"重要的"辅助检查结果才在病程记录中反映欠妥;对上级医师查房记录、死亡记录及死亡讨论记录在格式上的要求不如七版《诊断学》;实际工作中出院记录应在病人出院前完成,并有"一式两份"出院记录科室加盖印章的办法更好。建议今后在发布更新版的《病历书写基本规范》之前,先充分征求意见,尤其应征求最新版《诊断学》编写组的意见,避免二者不统一。
The defects in progress note of the New Basic Criterion of Documentation of the Medical Records are as follows： It has defects in definition for progress note;Only the results of ＇important＇ auxiliary examination are shown in progress note,which is not satisfactory;For the format of records of ward-round,death and death discussion,the demands for superior physicians were inferior to Diagnostics（7 th edition）;In new criterion,discharge records should be completed before discharge,which is also done in duplicate;Departments should have seals.Following suggestions are raised： before publishing a newer Basic Criterion of Documentation of the Medical Records,advices should be adequately consulted first,especially consulting for the writing group of Diagnostics,to avoid disunity between the two.
出处
《中国病案》
2010年第12期15-16,共2页
Chinese Medical Record
关键词
病历书写
规范
病程记录
The writing of medical records
Criterion
Progress note
