摘要
病历资料是医护人员进行医疗行为和过程的客观记录和文字见证,不仅是医疗质量的核心指标之一,还是医疗争议、医疗纠纷中重要的证据。外科病历不仅是医院外科手术能力建设的文字佐证,还是降低外科医疗风险,提高外科医疗核心质量的重要工具。因此,提升外科病历质量迫在眉睫。
The medical record is the objective record and proof of medical behavior and process. Medical record is not only one of the key indexes of medical quality but also the important evidence in medical dispute. Surgical medical record is not only the text evidence of the construction of hospital surgical operation ability but also an important tool to reduce risk of surgery and improve quality of surgical care. Therefore, it is urgent to improve the quality of surgical medical records.
出处
《医院管理论坛》
2016年第9期65-66,48,共3页
Hospital Management Forum
关键词
外科手术
手术分级
病历质量
Surgical operation
Operation classification
Quality of medical record
