摘要
病历是反映病人病情的全程记录,其中现病史是病历的核心部分,决定着病历的内涵和质量,体现着医师的敬业精神,具有重要的法律凭证作用。然而当前病历的现病史的书写质量令人堪忧,部分医生由于不认真或经验不足等原因,所写的现病史经常不能抓住书写要点,出现各种错误,如现病史与主诉脱节,文字描述错误等书写问题颇为普遍。临床医生应尽量避免出现现病史书写过程中的常见问题,提高现病史书写质量是作出正确的诊断及制定正确的诊疗方案的基础。
Medical recordsreflect the full process of the patient＇ s illness, in which＇the history of present illness is the core part, it is also an important legal instrument, determines the quality of the content and also reflects the professionalism of the physician at the same time. However, the current written quality of present illness history is not well. As the reasons such as careless or lack of experiences, some doctors often could not grasp the writing point and made various mistakes, for example, detachment of the history of present illness and chief complaint, text description error, and so on. Therefore, clinicians should try to avoid the common prob- lems in the writing of present illness history, and the improvement of the quality of present illness writing is the basis of making the correct diagnosis and developing the right treatment program.
出处
《中国病案》
2013年第6期22-23,共2页
Chinese Medical Record
关键词
现病史
病历
书写
History of present illness
Medical record
Writing
