病案书写规范实例分析  

Case Analysis on Writing Standard of Medical Record

作　　者：欧晖[1] 谭小燕[1] 李凌[1] 

机构地区：[1]广州市第一人民医院病案室,广州市510180

出　　处：《中国病案》2013年第8期16-17,共2页Chinese Medical Record

摘　　要：本文以案例分析的方法,针对由于病案首页填写错误、书写不及时、内容缺陷、记录不完整等问题而引起医患纠纷的情况进行分析,并提出规范病案书写;保证病案的完整性;健全病案质控体系等有效措施,从而有效地防范医患纠纷。Based on the method of case analysis, this article analyzed the medical disputes caused by problems such as error medi- cal record home page filling, not timely writing, content defects, incomplete recording, and put forward some effective measures to standard medical record writing, ensure the integrity of the medical record as well as complete the medical record quality control sys- tem, thus effectively prevent medical disputes.

关 键 词：病案书写 规范 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]