【作者】 冯怡；

【Author】 Feng Yi Department of Medical Record and Statistics,china-japan friendship hospital Beijing 100029 China

【机构】 中日友好医院病案统计室；

【摘要】 病案质量是医院医疗质量的组成部分。病案作为医疗信息的原始资料,在医院医疗质量管理中起着主要作用,病案质量的好坏直接影响医院的医疗质量。病案不但为医疗、教学、科研提供极其宝贵的基础资料,也为医院管理提供不可缺少的医疗信息。三级医师查房制度是我国卫生部门为保证患者医疗质量、医疗安全而制定的。因此,各级医师在病案书写过程中必须严格遵守病案书写规则,这对提高病案质量和医院管理水平非常重要。更多还原

【Abstract】 As the original record of patients’ medical information,medical record directly affects the quality and management of medical services.Medical records provide necessary medical statistics and educational information.The ward round system of three-levels doctors ensures patients to receive comprehensive medical services.Therefore,all doctors must follow the standard format while writing the medical records;this also leads improvements in hospital’s management Ward Round System by Tertiary Doctors is a basic role that doctors at all levels must abide by.Thus it would be very important and effective to strengthen ward round system if we want to improve the overall medical quality and management skills as well as training of younger docotors.更多还原