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2002年,卫生部、国家中医药管理局颁发的《病历书写基本规范》(试行)开始实施。对于规范和强化全国医疗卫生系统临床工作质量标准和法律意识起了决定性的作用。但是,有些内容需要修改和补充,特此提出建议。本文主要针对修改问题和需要修改的具体内容进行讨论。
In 2002, the “Basic Rules for Writing Medical Records” (Trial) issued by the Ministry of Health and the State Administration of Traditional Chinese Medicine began implementation. It has played a decisive role in standardizing and strengthening the quality standards and legal awareness of the national clinical health care system. However, some of the contents need to be revised and supplemented, and hereby make recommendations. This article mainly discusses the problem of modification and the specific content that needs to be modified.