对妇产科临床医师病历书写质量的关注与思考  

Seven Points of Consideration on the Quality of Medical Records Written by Obstetricians and Gynecologists

作　　者：胡晓星[1] 杨丹妮 李丽华[1] Hu Xiaoxing;Yang Danni;Li Lihua(Beijing Chaoyang Hospital Affiliated to Capital Medical University,Beijing 100020,China;不详)

机构地区：[1]首都医科大学附属北京朝阳医院,北京市100020 [2]首都医科大学附属北京友谊医院,北京市100022

出　　处：《中国病案》2023年第12期21-23,共3页Chinese Medical Record

摘　　要：妇产科临床医师完成结构化、半结构化妇科、产科高质量的病历书写,须依据专业技术特点写出妇科、产科临床诊疗过程中的重点与关键点。病案整体应当表达出临床工作中依法执行国家卫健委多种制度、法律、法规、行业标准、国家医保管理制度等;临床医师在病历书写过程中训练出正确的临床思维过程;表达出医师的人文关怀与高度责任心。关注病历书写中与基本医疗保障付费方式改革实施的相关信息,关注合理检查、治疗、用药、费用的完整记录,最终达到保证患者或孕产妇的医疗安全,获得最满意的诊疗结果。To complete the high-quality medical records of structured and semi-structured gynecology and obstetrics,gynecologists should write out the key points and key points in the clinical diagnosis and treatment of gynecology and obstetrics according to professional and technical characteristics.The medical record as a whole should express the implementation of the National Health Commission's various systems,laws,regulations,industry standards,and national medical insurance management system in accordance with the law in clinical work;The clinician trained the correct clinical thinking process in the process of writing medical records;It expresses the humanistic care and high sense of responsibility of doctors.Pay attention to the relevant information in the writing of medical records and the implementation of the reform of the payment method of basic medical security,pay attention to the complete record of reasonable examination,treatment,medication and cost,and finally ensure the medical safety of patients or pregnant women,and obtain the most satisfactory diagnosis and treatment results.

关 键 词：妇产科病案 书写质量 临床医师 

分 类 号：R197.323[医药卫生—卫生事业管理]