病历是非常重要的临床资料。住院医师对于临床病历书写的细节重视不够,而许多病历细节问题的不够重视可能直接影响医疗安全。上级医师应重视对住院医师临床病历细节的指导。病历中常见细节问题如病历顺序、自然项目、病情告知书签字、化验粘贴、病历中标点、文字涂改等,如得到良好的管理重视,可避免许多医疗差错,保障医疗安全。 Medical records are very important clinical data. Residents do not pay enough attention to the details of clinical medical records, and insufficient attention to many details of medical records may directly affect the medical safety. Senior physicians should pay attention to the details of residency clinical medical history guidance. Common medical records, such as the order of medical records, natural items, disease notification book sign, laboratory paste, medical records punctuation, text correction, such as getting good management attention, to avoid many medical errors, to ensure medical safety.