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有相当一部分临床医师不太重视病历记录。病历不仅具有重要的法律效力,而且是医学文稿的重要素材。有些医师在记录病历时,马马虎虎,对一些需要量化的指标不作具体测量和记录,随便采用约略叙述。待到后来,打算写成文章时,才感到很多问题说不清楚,后悔当初没能认真作好病历记录。事实上,确有很多值得写成文章进行交流的临床经验,由于病历记录不完备而报废了。这不仅是某个临床医师的损失,而且是整个医疗卫生事业的损失,是非常可惜的。
A considerable number of clinicians do not attach much importance to medical records. Medical records not only have important legal effects, but also are important materials for medical documents. Some physicians are meticulous in recording medical records and do not make specific measurements and records of some indicators that need to be quantified. Afterwards, when I was planning to write an article, I only felt that many problems were not clear. I regret that I failed to earnestly make a medical record. In fact, there are indeed many clinical experiences that are worth writing articles for communication. They are scrapped because the medical records are incomplete. This is not only a loss for a clinician, but also a loss for the entire health care industry. It is a pity.