Medical records are medical documents including words, symbols, charts, images, pathology and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records. The medical records written by doctors should be clear and clear. In fact, since 20 10, the former Ministry of Health promulgated the Basic Specification for Medical Records Writing, the phenomenon of scribbling medical records has been greatly improved. Because the specification clearly stipulates that medical records should be written with neat words, clear handwriting, accurate expression, fluent sentences and correct punctuation. Doctors who violate the standard requirements will be punished. However, in some private clinics and hospitals, doctors' medical records are still unclear.

Why can't most people read the medical records written by doctors?

This problem is common among the older generation of doctors. Before the introduction of the Basic Specification for Medical Record Writing, doctors wrote all kinds of medical records randomly. The reasons may be as follows:

1. Time limit for seeing a doctor

In the past, because the number of doctors was relatively insufficient, doctors needed to see many patients every day, and the income of doctors was also linked to the registration fee. In order to see as many patients as possible, they will choose to save time on things that are considered unimportant, such as writing medical records, which leads to sloppy medical records, concise language and even the use of abbreviated medical terms.

The problem of insufficient time for doctors to see a doctor is still widespread. There are hundreds of patients in the clinic every day. How do doctors write medical history and take medicine slowly? Even with the help of electronic information, he can't explain the contents of medical records to patients in detail. This point calls on relevant departments to pay attention to and solve the problem of doctors' excessive burden of seeing a doctor.

2. Personal writing font problems and attitude problems

Some doctors got into the bad habit of doodling when they were studying medicine. Because medicine needs to learn more than other majors, and there are a lot of records to write, in order to finish our homework quickly, we can only dance in fonts, and this habit has always been retained in our work.

3. In order to keep patients.

In some private clinics or hospitals, there may be doctors who write the medical records so that only he can understand them, and other doctors can't understand them at all, so if the patient needs a follow-up visit, he can only go back to him. Of course, there are relatively few such reasons.

In short, at present, many general hospitals have carried out information construction and implemented electronic medical record systems. Doctors no longer need to write medical records by hand, they can type on the computer, and patients no longer can't understand the contents of doctors' medical records. Moreover, with the vigorous publicity of network science popularization, people's awareness of medical-related knowledge is getting higher and higher, and they all know that they have the right to know. I believe that if the medical records are unclear and incomprehensible, there will be fewer and fewer problems in this regard.