在病历书写过程中,由于医务人员粗心大意或不经意地忽略某些细节而引起的常识性、低层次的错误称“病案低级错误”。其成因大致是由于拷贝病案未认真修改或三级监控未落到实处、未按规范时效书写病历、动手者与动笔者信息不对称等所致。防止“低级病案”应从几个方面入手:提高医护人员的法律意识和责任意识,增强工作责任心;加大监控力度,多管齐下,多方位监督,及时反馈病历质量检查信息,终末质控实行拉网式的检查,在病历形成的各个环节进行认真细致而又有效的控制。 In the process of writing medical records, common sense and low-level mistakes caused by careless or inadvertent ignorance of certain details by medical personnel are called “low-level errors in medical records.” The cause of this is roughly due to the fact that the copy medical record was not carefully modified or the three-level monitoring was not implemented, the medical history was not written according to the standard, and the information asymmetry between the hands and the author was caused. Prevention of “low-level medical records” should start from several aspects: improve the awareness of legal awareness and responsibility of medical staff, and enhance the responsibility of work; increase monitoring, multi-pronged, multi-directional supervision, timely feedback of medical record quality inspection information, and finally The end quality control implements a pull-net type inspection, and carries out careful and meticulous and effective control in all aspects of the medical record formation.