住院病历质量评定标准——病历书写规范（Medical record quality evaluation standard -- medical record writing standard）.docVIP

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住院病历质量评定标准——病历书写规范（Medical record quality evaluation standard -- medical record writing standard）.doc

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住院病历质量评定标准——病历书写规范（Medical record quality evaluation standard -- medical record writing standard）

住院病历质量评定标准——病历书写规范（Medical record quality evaluation standard -- medical record writing standard） Medical record quality evaluation standard -- medical record writing standard 2007-3-24 14:22 [big and small] [I want error correction] Inpatient medical records quality evaluation standard (total score 100 points) The standard requirement of the project is divided into the standard of deduction Home page and There is Xiang Bitian on the front of the eyebrow column The medical record is complete The medical record is completed within 24 hours 6 a missing item and 0.2 deducted Write off a deduction of 0.2 points More than 24 hours to complete the deduction of 4 points, did not specify when and how many points deducted 1 points main V. concise, not more than 20 words Completeness: symptom + (spot) + time Can produce first diagnostic symptoms without diagnostic terms 8 long, more than 20 words, buckle 2 points Incomplete, missing part of the deduction 4 points Cannot produce first diagnostic deduction of 4 points Take the diagnosis for chief complaints and deduct 4 points (except for asymptomatic exceptions) illness History should be closely integrated with the chief complaint There is a need for differential diagnosis data Reflects the development and change of major diseases The process of diagnosis and treatment before admission is briefly described Outstanding focus, clear levels and clear concept Past history, systematic review, personal history, marriage, menstruation, childbearing history, and family history are complete. Epidemic diseases should have a history of epidemic diseases 15 is not closely associated with the complaint, 3 points deducted There is no necessary differential diagnostic data for 2 points Can not reflect the main symptoms and the course of development and change, 5 points deducted Current medical history only lists past treatment or examination procedures and deducted 3 points Medical history, confusion, reversal, unclear levels, 3 points Missi