1) documentation of the medical record
病案书写
1.
The documentation of the medical record is one of the basic training for the interns,however,there are a lot of problems in the documentation of the medical record for the interns because only the skills of diagnosing and treating are generally emphasized,which influenced the quality of the medical record and the future clinical work of them as well.
病案书写是重要的临床基本功之一,但由于目前的临床实习普遍只重视临床诊疗技能的培训,导致实习医生书写的病案存在不少问题,既影响医院总体病案质量,也不利于将来的临床工作。
2) writing program
书写方案
3) 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。
4) 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。
5) case history writing
病史书写
1.
Grade analysis to case history writing of Chinese Medical Qualification Examination;
2003年上海地区中医医师资格考试病史书写考试分析
补充资料：病案
1.病历。
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