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本文从提高疗养工作质量角度,分析了当前本院疗养档案管理存在的主要问题及不足。表现在疗养档案书写不够规范,错、漏、涂改现象时有发生,部分内容没有按疗养技术常规要求填写,疗养效果评价内容不充分,疗养过程记录缺乏个性分析,心理测评治疗开展不够广泛,利用先进手段进
In this paper, from the perspective of improving the quality of recuperation, the main problems and shortcomings in recuperation file management in our hospital are analyzed. It is reflected in the inadequacy of standardization, error, leakage and alteration of medical records. Some of them are not filled according to the general requirements of medical treatment and nursing care. The content of medical treatment evaluation is not sufficient, the analysis of medical records lack of personality analysis, psychological evaluation and treatment are not widely used, Advanced means into