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目的调查临床常见的疾病诊断书写缺陷,探讨改进方法。方法参照“广东省病历书写规范”,检查我院2005年共18005份出院病案的疾病诊断书写情况。结果(1)主要诊断选择错误：(2)疾病诊断名称,手术操作名称书写不完整；(3)损伤和中毒外部原因漏填或填写不具体。结论重视疾病诊断的正确书写,有利于提高病案的信息价值。
Objective To investigate the clinical common disease diagnosis and writing defects and explore the improvement methods. Methods According to “Guangdong Provincial Medical Record Writing Standards”, we examined the disease diagnosis and diagnosis of 1,805 hospital discharge cases in our hospital in 2005. Results (1) Major diagnostic selection errors: (2) name of disease diagnosis, incomplete description of surgical operation name; (3) external causes of injury and poisoning. Conclusion Paying attention to the correct writing of disease diagnosis will help improve the information value of medical records.