《病历书写基本规范》新旧比较  

Comparison of New and Old edition to Basic Norms of Medical Records Writing

作　　者：倪静[1] 王艳萍[1] 封宗超[1] 孙娜[1] 

机构地区：[1]成都军区总医院质量管理科

出　　处：《中国病案》2010年第11期20-21,共2页Chinese Medical Record

摘　　要：通过对《病历书写基本规范》与《病历书写基本规范(试行)》的对比分析,归纳出《病历书写基本规范》的主要变化,其在要求上更加详细;对时间、手术安全、知情同意书等要求更加规范;同时提出了计算机打印病案的要求等。内容更具科学性、规范性和指导性,操作性也更强,进一步强化了病历的法律效力。通过分析对比,找出共性与特性内容,使医师更快掌握新规范。through comparing Basic Norms of Medical Records Writing and Basic Norms of Medical Records Writing （trial implementation）, this paper sum up the main change of Basic Norms of Medical Records Writing, which contains more details about requirements; more further norms about time, surgery safety and informed consent document; as well as requirements about computer printing medical records etc. Its content is more scientific nature, standardization, instructiveness, operability. The new edition further intensifies legal effect. Through analyzing and comparing, the paper finds out general character and peculiarity between the new edition and the old one that made the doctor to master the new norm faster.

关 键 词：病历书写 病案质量 规范 

分 类 号：R197.3[医药卫生—卫生事业管理]