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病案管理中的医学伦理问题越来越受到人们的关注,正在我国进行的医疗体制和社会保障机制的改革,医疗法制尚不健全,医患纠纷日益增多。在现代医院管理中,随着医院技术设备的现代化,病案作为医疗活动信息的主要载体,不仅是医疗、教学、科研的第一手资料,而且也是医疗质量、技术水平、管理水平综合评价的依据。如何高效、准确、及时管理病案、及时反馈病人所有信息、及时了解医护人员对病人护理的历史记录,是医疗信息化建设的奋斗目标,因此,医院必须相应培养一支具有良好素质的病案管理队伍,以进一步加强病案管理工作,确保医院的宏观调控和科学管理的实施。
Medical ethics in medical record management has drawn more and more attention. Reform of the medical system and social security system in our country is still underway. The medical legal system is still not perfect, and the disputes between doctors and patients are increasing day by day. In modern hospital management, with the modernization of hospital technology and equipment, medical record as the main carrier of medical activity information is not only the first-hand information of medical treatment, teaching and scientific research, but also the basis of comprehensive evaluation of medical quality, technical level and management level . How to effectively, accurately and promptly manage medical records, timely feedback of all patient information, and keep abreast of the history of patient care by medical staff is the goal of medical informatization. Therefore, hospitals must cultivate a contingent of medical record management personnel with good qualifications In order to further strengthen the management of medical records and ensure the implementation of macro-control and scientific management in hospitals.