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为了充分发挥(副)主任医师在病历质控中的主体作用。分析(副)主任医师查房中存在的主要问题,如查房中没有体现出应有的专业水平、未认真审阅下级医师书写的病历记录、忽视亲自向患者告知重要事项、甚至未能履行查房职责。应采取有效措施保证(副)主任医师在病历质控中的主体作用,如制定岗位职责、定期进行查房提出对诊断治疗的意见、审阅修改下级医师书写的病历记录等。从而提高临床诊疗水平与医疗安全。
In order to give full play to (chief) chief physician in the quality control of medical records in the main role. Analysis of the (deputy) chief physician rounds out the main problems, such as rounds did not reflect the professional level should be, did not seriously review the medical records written by the lower physician, ignoring the patient personally informed of important issues, or even failed to perform investigation Room duties. Effective measures should be taken to ensure that the (chief) chief physician plays a major role in the quality control of medical records. For example, job responsibilities are formulated, opinions on diagnosis and treatment are regularly made on the rounds, and records of medical records written by lower physicians are reviewed and revisited. Thus improving the clinical diagnosis and treatment level and medical safety.