Survey of the standardization of medical records writing by physicians / 中华医院管理杂志
Chinese Journal of Hospital Administration
;
(12): 12-15, 2011.
Artigo
em Chinês
| WPRIM
| ID: wpr-413373
ABSTRACT
Objective To study the standardization of medical records writing by residents in hospitals. Methods With both quantitative and qualitative analysis, medical records made by residents were sampled in groups to study their standardization. Results Recognition rate of such medical records was 82. 55%, and the excellence rate was 24. 50% in the grade evaluation. For senior residents, their rate of writing excellence falls below those of junior ones; whether the evaluators have medical background bears no significant difference for grade evaluation of medical records writing, yet a significant difference was found with the recognition rate. Conclusion Writing of medical records by residents is found with incompliance now and then, and the recognition rate ought to be improved.
Texto completo:
DisponíveL
Índice:
WPRIM (Pacífico Ocidental)
Tipo de estudo:
Pesquisa qualitativa
Idioma:
Chinês
Revista:
Chinese Journal of Hospital Administration
Ano de publicação:
2011
Tipo de documento:
Artigo
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