病历缺陷的医院管理与卫生监督干预初探

目的全面推行依法行医观念，尝试医院管理与卫生监督的有效结合，以减少病历书写缺陷，提升病历书写质量，规范医疗行为。方法对1家试点医疗机构病历书写规范进行卫生监督干预研究。结果医疗机构的病历书写不规范情况有所改善。结论病历书写不规范现象通过医院管理与卫生监督有效改善是～种有效尝试。

To explore the medical record defects intervention way on the hospital management and health inspection

Objective： To fully implement the concept of law practice, and to explore the effective integration of hospital management and health inspection on the aim of reducing the defects in medical record and enhancing the quality of medical writing and standardizing the practice in medical care. Method： To do research on a pilot medical institution in the intervention of inspection on the medical record writing. Results： The writing quality of medical records has been improved. Conclusion： One effective way to improve medical writing is the application of the hospital management and health inspection.