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文章阐述了法律文书与法律文件的含义,批驳了有些文章中经常把病案称作是法律文件,将医师书写的病历记录和护士所做的护理记录、医嘱记录说成是法律文书,是一种极大谬误,是一些人员对病案认识上的误差。强调了病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和,是医务人员在为患者施治疾病过程中为了疾病观察、连续医疗的依据。通过所列举的有关案例,提示医务人员只有遵守客观、真实、准确、及时、完整、规范的书写病历,才能有效维护医疗工作的合法权益。
The article elaborates the meaning of legal documents and legal documents, criticizes the often recorded cases as legal documents in some articles, medical records written by physicians and nursing records made by nurses, and records medical orders as legal documents, which is a kind of legal document Great fallacy, some people on the medical record of the error. Emphasized that the medical record refers to the sum of the characters, symbols, charts, images, slices and other information formed by the medical staff during the course of medical activities. It is the basis for the medical staff to observe diseases and carry out continuous medical treatment during the course of curing diseases for the patients. Through the listed cases, it is suggested that medical personnel can effectively protect the legal rights and interests of medical work only by obeying objective, true, accurate, timely, complete and standardized written medical records.