中新网太原11月22日(范丽芳 通讯员郝东亮)近日一份字迹潦草的医生处方在网上快速扩散，网民调侃其为自创的“医生体”，并纷纷吐槽各自看病经历，称完全看不懂病历内容。22日，山西晋中病历质控部主任邢晓冰称，病历书写已陷入困境，错字、别字、漏字常见，“有时整个病历本一个标点‘.’就能点到底。”

Taiyuan in Beijing on November 22,(FanLiFang correspondent HaoDongLiang)Recently a with scribbled a prescription from a doctor in the online fast diffusion,Netizens poking fun at the self-initiated"The doctor body",They spit tank their experience to see a doctor,Say completely don't understand the medical record content.22,Jinzhong shanxi medical record quality control department XingXiaoBing says,Case file writing are already in trouble,misprint/Ghost word/Pragraphs common,"Sometimes the whole BingLiBen a punctuation‘.’Can point exactly."

　　写好病历，是每一位临床医生必须具备的基本功，也是临床医生必须认真完成的诊疗任务。但提到病历本，多数有过就医经历的人对医生字体“不敢恭维”；而山西省医调委的资料显示，由于病历书写不规范引发的医疗纠纷屡有发生，病历单纯为医院医教研服务的时代已经结束。

Write good medical records,Is each clinical doctors must have basic skill,Also clinical doctors must be carefully completed task diagnosis and treatment.But BingLiBen mentioned,Most had medical experience to the doctor font"Dare not flatter";And shanxi medical adjustable committee data shows,Due to the medical record writing is not standard cause of medical disputes to sometimes occur,Medical records in hospital simple YiJiaoYan service era is over.

　　“病历的功能正在扩大，它是刑事民事伤害案件中的证据、商业保险理赔的根据、医疗事故发生时的鉴定依据，同时还要面对患者及社会的挑剔。”邢晓冰介绍，传统的病历书写要求受到新形势的冲击和挑战，如何规范病历书写，成为医务人员面临的新问题。”

"The function of the medical records is expanding,It is criminal civil damage cases the evidence/Commercial insurance claims based on/Medical accident happens appraisal basis,At the same time also face patients and society's fault."XingXiaoBing introduced,The traditional medical record writing by the new situation for the impact and challenges,How to regulate medical record writing,Become a new problem faced by the medical staff."

　　在分析大量病历后，晋中病历质控部门工作人员总结称，目前病例中常见的问题包括不注意核对患者基本信息；捏造、篡改、盲目拷贝病历；病历前后描述矛盾；语文基础差；字迹潦草、签名不清楚或代替他人签名；不规范缩写等。

On the analysis of a large number of after medical records,Jinzhong medical records quality control department staff summary said,At present cases common problem including do not pay attention to check the basic information about the patients;fabricated/Tamper with/Blindly copying medical records;Before and after the medical records described contradictions;Language foundation is bad;With scribbled/The signature is not clear or instead of others' signature;Is not standard abbreviation, etc.

　　“我们对住院、出院、转诊记录甚至化验单的粘贴都有严格规定，如病历书写出现错字，应当用双线划在错字上，而不能采用刮、粘、涂等方法掩盖。”晋中市中医院解晓红介绍。

"Our hospital/discharge/Referral record even laboratory sheet of paste have strict rules,Such as case file writing appear the wrong character,Should use double row in the spelling,And cannot use the scraping/sticky/Methods such as coating cover."Jinzhong city hospital of traditional Chinese medicine XieXiaoGong is introduced.

　　一位不愿具名的医务人员称，医生出门诊时都是高强度、快节奏的工作，一天要看几十个病人，为了节约时间，难免出现了“医生体”。

An anonymous medical researchers said,The doctor out of outpatient service is high strength/The fast pace of work,One day to see dozens of patients,In order to save time,Appears unavoidably the"The doctor body".

　　对此，邢晓冰提醒，病历作为一种书证，其证明力一般大于其他物证，而当这些存在问题的病历在法庭上作为证据使用时，成为医院、医师赤裸裸的“硬伤”。(完)

this,XingXiaoBing remind,Medical records as a documentary evidence,The proof force general than other material evidence,And when these existing problems of the medical record in court when used as evidence,Become hospital/Doctor naked"Mechanical damage".(finish)