《病历书写基本规范》是对住院病历质量进行规范管理和书写指导的标准文件。在医院的独特管理作用和应用指导性能非其他文件可以替代。制定和完善《病历书写基本规范》不能仅仅局限于文字或内容的增减,要研究管理理论,明确管理标准,完善管理细节。这是医院基础医疗管理的重要内容。本文围绕这一话题提出几点讨论意见。 “Basic Medical Records Writing” is a standard document on the standardized management of hospital medical records and writing guidance. The unique management role in the hospital and the application of guiding performance can be replaced by other documents. To develop and improve the “basic norms of medical records” can not be limited to the increase or decrease of text or content, to study management theory, clear management standards, improve management details. This is an important part of hospital basic medical management. This article raised some discussions on this topic.