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《Chinese Medical Record》 2010-09
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Investigation on Problems in Machine-printed Medical Record

Chen Gang,Hu Xiaodong,Medical Department of the 253th Hospital of People's Liberation Army,Huhehaote 010050,Inner Mongolia Autonomous Region,China  
Objective To investigate the problems existed in the writing of medical records in order to propose countermeasures. Methods The problems existed in the writing of medical records were analyzed,especially the debates in machine-printed medical records. Results Following issues should be clarified,including diagnosis items in admission records,three-level examination records,course records repagination,arrangement of page number,reliability of medical history and barcode label of implanted instrument. Conclusion Details of writing criterion of medical records and various documents examples need to be further perfected.
【CateGory Index】: R197.3
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