Medical records writing is indispensable in the clinical practice,and it is also the clinical skills that interns must have.
病历书写是临床实践中不可缺少的工作,也是实习医师必须掌握的临床技能。
The documentation of the medical record is one of the basic training for the interns,however,there are a lot of problems in the documentation of the medical record for the interns because only the skills of diagnosing and treating are generally emphasized,which influenced the quality of the medical record and the future clinical work of them as well.
病案书写是重要的临床基本功之一,但由于目前的临床实习普遍只重视临床诊疗技能的培训,导致实习医生书写的病案存在不少问题,既影响医院总体病案质量,也不利于将来的临床工作。
Based on the experiences of clinical quality control and check of the medical record for many years,we discussed the impaet and requirement of the diagnosis which acts on clinical medicine,and analyzed the types,requirement,format,and others related to the diagnosis.
在现有的病历书写规章制度中,有关诊断的书写标准和要求不够完善和规范,因而也限制和影响了临床医师的思维和书写。
The rules and regulations of documentation of the medical record concerning the definition of the chief complaints and their criterion should be changed and developed in order to adapt the constant changing of medicine service.
文章提出了在医院医疗服务范围和项目不断拓宽的情况下,现行病历书写规章制度中有关“主诉”的定义和书写要求也应进一步修改和拓宽。
Grade analysis to case history writing of Chinese Medical Qualification Examination;
2003年上海地区中医医师资格考试病史书写考试分析
Using Process Management to Improve Nurse Records Quality
应用流程管理提高护理病历书写质量
Research on the Method of Process Management in the Quality of Nursing Records;
过程管理方法在护理病历书写质量中的应用研究
Establishment and application of nursing writing mode in electronic case file
电子病历中护理书写模式的创建与应用
The characteristics ethics of documetation in para-operation records
围手术期病历书写中的医学伦理学特点
Practice to improve the quality of nursing records for patients with diabetic ketoacidosis
糖尿病酮症酸中毒护理记录书写方法的改进
Strengthening Case File Writing and Improving Outcomes of Neurological Practice;
强化病历书写 提高神经病学实习效果
Study for the effect on the quality of nursing writing document and the impact of diversity management strategy
多元化管理对护理文书书写质量的影响
Progressive Write Checks and Improve the Quality of Medical Records;
医务科对医疗病历书写持续检查分析和改进
Problems and Countermeasures of Medical Records Written by Pediatric Trainees
儿科实习生病历书写存在的问题与对策
To Elevate the Effect of Inspections on Medical Records Written by Interns
从病历书写论实习、试用期医务人员的监管成效
Objective To make nursing notes perfect and improve quality of nursing notes.
为了完善护理记录,提高护理记录的书写质量。
Analysis on Errors in Writing Orthopedic Nursing Records and Countermeasures
骨科护理记录书写缺陷分析与对策
The practice and effect of three-level quality control system on the quality of nursing records
护理记录书写质量控制的方法与效果
Clinical psychologists might write fascinating histories.
由心理病学家来写历史，可能写得十分精彩。
Practice and experience of pathology standardized lesson plan writing
病理学规范化教案书写的实践和体会
Analysis on the reasons and countermeasures of the common problems in nursing documentation
护理文件书写中常见问题原因分析与对策
Application of multi-station quality control to nursing records
用“多站式”质控方法进行护理文书书写质量的管理
Some Experiences on Improving Orthopaedics Medical Record Writing Quality of Seven-year Medical Students
提高七年制医学生骨科病历书写质量的几点体会