Netizens ridicule "hieroglyphics" records: this is the mysterious code? -Case friends, hospital-IT information
Recently, the net exposure in Jiangsu lienyungang city people "to go to the hospital, found medical records and prescriptions written by doctors handwriting handwriting is difficult to read! "The news triggered netizens collectively ridicule again. In recent years, the more exposed the doctor write medical records scribbled random, like "double Dutch" disease unpredictable.
Health sector in China in 2010 to develop the fundamental norms of medical records request medical records should regulate the use of medical terminology, text neat, legible, and accurate statements, and punctuation are correct. However, this regulatory effect is not so obvious for 6 years. "Greek record" no hard, whether it is a doctor too busy or hospital management? Handwritten medical records how the specification?
Scribble records common
"Doctor′s handwriting, calligraphy, sloppy, written on the prescription drug name, it is illegible! "In recent days, media reports said Mr Zhang, who lives in Lianyungang city, Jiangsu ganyu area reflects, in the course of his visits, from the hospital to the township hospital medical records and prescription handwriting is difficult to read.
Journalists on Twitter dispensing "medical record" seen on the picture, and scrawled the shape of a section of the curve, integrated stroke is almost illegible, even date fill in the upper right corner of the Arabic out of all recognition.
After this picture spread through the network, Internet users aroused strong concern and empathy. Netizen "lute" says: "never pay attention, now turn over a record jump, can recognize a few words. Fonts of the original doctor, from small to large I do not know, thought it was some kind of code that protects patient privacy, I called this font is called ′ doctor. ′ "Netizens" one corner "said:" I have always thought that the doctor prior to employment and will train a special handwriting for doctors! ”
Due to the doctor too busy?
Zhu Endocrinology clinic at a hospital doctor told reporters, working for more than 10 years has developed the habit of quickly written, and some common terminology to avoid passing. "I sat the general outpatient clinics, more than half a day to see more than 60 patients, from the Inquisition to open medical record, a patient can only stand to 3-5 minutes. "She said that medical records generally have more than more than 100 words, for frequent words, most of the time can only be simplified, or writing time, and time is reduced.
However, doctors writing illegible medical records due to busy with work, some netizens queries and concerns. Netizen "courage live" says: "busy with work you can casually writing it? If a doctor to write medical records lacked the patience, what about interrogation and how to do it calmly? ”
However, the Health Department said as much, to be checked every year to urge implementation of the fundamental norms of medical records, most hospitals have established self-check mechanism, through routine inspections found that sloppy medical prescription will be seriously dealt with. A year ago, Zhejiang has 7 doctors writing illegible illegible medical records, hospital withheld bonuses.
Implementation of electronic medical records
Peking Union Medical College, school of public health Dean Yuanli Liu believes that appear scrawled records phenomenon is partly due to some medical workers have not been strictly regulated training, did not form a good habit of taking patient as the Center caused by; the other is doctor′s workload, to see too many patients, considerations of speed than the emphasis on quality.
"Change doctors ′ illegible medical records ′ situation, one of the best practices is the implementation of electronic medical records. With the popularity of our electronic medical records and medical inputs and to the cause of development, ′ Heavenly Records ′ will be history. "Yuanli Liu said.
网友吐槽“天书”病历：这是神秘代码？ - 病例,网友,医院 - IT资讯
近日，网曝江苏连云港市一市民“去医院看病，发现医生写的病历和处方上的字潦草难认！”的消息再次引发网民集体吐槽。近年来，全国多地曝出医生书写病历潦草随意，甚至酷似“天书”，让病患者捉摸不透。
我国卫生部门2010年制定的《病历书写基本规范》要求，病历书写应规范使用医学术语，文字工整，字迹清晰，表述准确，语句通顺，标点正确。然而，6年来这一规章效果不甚明显。“天书病历”难绝，到底是医生太忙还是医院疏于管理？手写病历该如何规范？
潦草病历司空见惯
“医生写的字，龙飞凤舞的，很潦草，处方上写的药品名称，更是难以辨认！”近日，有媒体报道称，家住江苏连云港市赣榆区的张先生反映，在自己就诊过程中，从乡镇医院到大医院都存在病历和处方本字迹难认的情况。
记者在微博配发的一张“病历记录”图片上看到，字迹潦草形似一条条曲线，笔画几乎连成一体，难以辨认，就连右上角日期位置填写的阿拉伯数字也认不出来。
这张图片经网络传播后，引起网民强烈关注和共鸣。网民“卢特仔”说：“以前没注意，现在翻开病历才吓一跳，能认出的没几个字。原来医生的字体，我从小到大都看不懂，还以为是某种代码，保护病人隐私，我称这种字体叫‘医生体’。”网民“程一得阁”说：“我还一直认为医生就业前，会培训一种医生专用手写体！”
缘于医生工作太忙？
在一家医院内分泌科坐门诊的朱医生告诉记者，工作10多年来已经养成了快速书写的习惯，有的常见专业术语难免一笔带过。“比如我坐的这个普通门诊，半天时间要看六十多个病人，从问诊到开病历，一个病人只能摊到3至5分钟。”她说，病历一般有100多字内容，对于频繁出现的字，很多时候只能简化，不然书写的时间多了，看病的时间就要打折扣。
然而，医生把病历书写潦草归结于工作忙，引起部分网民质疑和担心。网民“勇敢的过日子”说：“工作忙就可以胡乱地书写吗？如果医生连写病历都缺乏耐心，那问诊又怎么能够做到心平气和呢？”
但是，多地卫生部门也表示，每年都会不定期检查督促落实《病历书写基本规范》，大多数医院也建立了自查机制，通过日常巡查发现潦草病历处方将严肃处理。一年前，浙江就有7位医生因书写病历潦草难认，被所在医院扣发奖金。
应当推行电子病历
北京协和医学院公共卫生学院院长刘远立认为，出现潦草病历的现象一方面是由于一些医务工作者没有经过严格规范的训练，没有养成良好的以病人为中心的习惯所造成的；另一方面是医生工作量大，要看的病人太多，对速度的考量大过对质量的重视。
“改变医生‘潦草病历’的局面，最好的做法之一是推行电子病历。随着我国电子病历的普及和医疗事业的投入及发展，‘天书病历’终将会成为历史。”刘远立说。