【摘要】 分析病历书写的重要性以及病历书写与医疗纠纷的关系,通过对我院2007年3月-2007年9月份归档病历检查886份和平时抽查科室运行病历进行持续质量评审,对医疗文书书写质量存在问题及时采取措施,强化医疗文书的规范性和法律性,使医疗文书质量不断得到提高,使归档病历甲级率达到95%以上,逐步消除乙级病历,杜绝丙级病历,符合《病历书写基本规范(试行)》,并且提高了各级医师医疗水平,促进了临床医疗质量的提高,减少了医疗纠纷的出现,避免了重大医疗事故的发生,提高了病人就医的满意度,使医务人员全身心地投入到为病人的诊疗活动中去。更多还原

【Abstract】 Analyze the importance of the medical records,the relation between the medical record and medical disputes.Through 2007-3～2007-9,the annual medical checks sections 886 and in quality accreditation inspection analysis,the quality documentation writing problems take measures to strengthen medical normative,and legal instruments to progressive improve the quality of medical instruments for filing medical records A-class-rate 95%,decrease B-class record,avoid C-class record,also improve the doctors medical skill and the whole hospitals medical treatment quality.更多还原