2) medical records writing
病历书写
1.
Medical records writing is indispensable in the clinical practice,and it is also the clinical skills that interns must have.
病历书写是临床实践中不可缺少的工作,也是实习医师必须掌握的临床技能。
3) medical record
病历书写
1.
Based on the experiences of clinical quality control and check of the medical record for many years,we discussed the impaet and requirement of the diagnosis which acts on clinical medicine,and analyzed the types,requirement,format,and others related to the diagnosis.
在现有的病历书写规章制度中,有关诊断的书写标准和要求不够完善和规范,因而也限制和影响了临床医师的思维和书写。
2.
The rules and regulations of documentation of the medical record concerning the definition of the chief complaints and their criterion should be changed and developed in order to adapt the constant changing of medicine service.
文章提出了在医院医疗服务范围和项目不断拓宽的情况下,现行病历书写规章制度中有关“主诉”的定义和书写要求也应进一步修改和拓宽。
4) nursing writing
护理书写
1.
The present situation and countermeasures of proper nursing writing in ascertaining responsibilities;
护理书写适应举证责任倒置的现状及对策
5) Nursing record
护理病历
1.
Objective To explore the causes of defects in nursing record in department of gynecology and obstetrics,and to improve nursing record writing.
目的探讨妇产科护理病历书写缺陷的原因,提高护理病历书写质量。
2.
Method: Spot-checked 200 sets of medical records from April to December in 2003, analyzed and marked following the standards of “ Nursing record writing standard of Guangdong province".
目的 :探讨现阶段护理病历存在的问题 ,并提出相应的对策 ,以提高护理病历书写质量 ,适应《医疗事故处理条例》的要求。
6) Nursing records
护理病历
1.
To discuss the defects of death nursing records.
目的探讨死亡护理病历存在的缺陷问题。
2.
To discuss the supervisal of integral quality of nursing records, the author introduces a series suitable, simple and normative nursing forms, and makes matching quality control method and management measures, gives references to integral nursing records supervisal.
为探讨整体护理病历质量的监控与管理 ,本文介绍了一套适合该院实情 ,且简洁、规范的整体护理表格系统 ,并制定了与该表格系统相匹配的质量监控手段和管理方法。
3.
Objective Process management is a method in controlling the quality of nursing records.
研究目的 通过在医院骨科病房实行护理病历过程管理,探讨医院病房运用环节质量控制方法保证护理病历质量的有效途径,分析护理病历书写质量现况,明确护理病历书写的影响因素和流程,制定护理病历书写质量过程管理方法的模式和步骤,其结果可为医院护理管理实行环节质量控制提供依据,指导临床护理管理者和临床护理人员正确控制护理过程质量,保证护理终末质量。
补充资料：病历
1.医疗部门记载病情﹑诊断和处理方法的记录。每个病人一份。
说明：补充资料仅用于学习参考，请勿用于其它任何用途。
参考词条