门诊病历的常见缺陷及对策  

The Defects in Out-patients' Medical Records and Relevant Countermeasures

作　　者：周晓琴[1] 龙雅玲[1] 霍胜军[1] 

机构地区：[1]湘潭市第一人民医院病案管理科,湘潭市411101

出　　处：《中国病案》2012年第9期6-8,共3页Chinese Medical Record

摘　　要：通过调查门诊病历书写中存在的缺陷,深入分析门诊病历缺陷产生的社会、医院、医师等各方面的原因,探讨在门诊病历格式上的合理改进,三级质控机制的落实、加大监管力度等方法,努力提高门诊病历质量。To investigate the defects existing in out-patients＇ medical records, and analyze its reason from aspects such as hospital, society and doctors. Then discuss the appropriate improvement measures in the style of out-patients＇ medical records, put three-level quality control mechanism in- to practice, strengthen supervision, and finally improve the quality of out-patient records.

关 键 词：门诊病历 缺陷 对策 

分 类 号：R197.3[医药卫生—卫生事业管理]