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目的从诊断、医嘱和病程记录三者间关系探讨临床医师如何写好住院病历。方法查阅2000年至2007年我院病案室登记用于备查的“优秀病历”共70份,重点查看病程记录、诊断、医嘱。结果我院的“优秀病历”普遍内涵质量不高,虽然第一诊断正确,但入院后发现的合并症和并发症交代不清,从而导致诊疗计划欠缺,病程记录满足于第一诊断,而忽视了对合并症和并发症的分析描述。结论一份合格的病历应入院诊断准确、诊疗计划完整、病程记录内容详实。应着重于从诊断、医嘱和病程记录三者间关系来写好病历,提高病历内涵质量。
Objective To discuss how clinicians can write inpatient medical records from the relationship among diagnosis, doctor’s advice, and disease history. Methods A total of 70 “excellent medical records” registered in the medical record room of the hospital from 2000 to 2007 were examined for the records of the disease, diagnosis, and medical records. Results The general connotation quality of our hospital’s “excellent medical records” is not high. Although the first diagnosis is correct, the comorbidities and complications found after admission are unclear, resulting in a lack of medical treatment plans, and the disease record is satisfied with the first diagnosis. Ignoring the analysis of complications and complications described. Conclusions A qualified medical record should be accurately diagnosed on the admissions, the diagnosis and treatment plan should be complete, and the course of illness should be recorded in detail. Should focus on the relationship between the diagnosis, medical records and history records to write a good medical record, improve the quality of medical records.