Grayson M A
Hosp Med Staff. 1979 Mar;8(3):21-5.
The medical record is the wellspring of data for countless medical staff and administrative decisions. Even though the ancillary activities that depend on the medical record have received most of the attention in recent years, the most common problem encountered by medical and hospital staffs is probably as old as the concept of the medical record itself--completing it in a timely and accurate manner. This article details how three hospitals keep the number of incomplete charts in check.
病历是无数医务人员和行政决策的数据源泉。尽管近年来依赖病历的辅助活动受到了大部分关注,但医疗和医院工作人员遇到的最常见问题可能与病历概念本身一样古老——及时、准确地填写病历。本文详细介绍了三家医院如何控制不完整病历的数量。