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目的规范医务工作者的病历书写,提高书写质量。方法分析病历书写中存在的问题。针对出现的问题,提出解决方案。结果病案中存在的主要问题是,对书写认识不够、书写不规范、字迹不清、难以辨认以及法律意识淡薄等,导致病历书写中存在很多问题。结论开展继续教育学习、提高认识和加强思想教育,以及制定完善的奖惩措施等,可以有效的提高病案书写质量。
Objective To standardize the medical records writing of medical workers to improve the writing quality. Methods Analyze the existing problems in medical record writing. For the problems that arise, put forward solutions. Results The main problems in the medical record were the lack of understanding of the writing, the nonstandard writing, the illegible writing, the illegibility and the weak legal consciousness, which caused many problems in the writing of medical records. Conclusions Carrying out the study of continuing education, raising awareness and strengthening ideological education, and formulating and improving reward and punishment measures can effectively improve the quality of medical record writing.