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病案是医务人员记录疾病诊疗过程的文件,它客观、完整、连续的记录了病人的病情变化、诊疗经过、治疗效果及病情最终转归,是医疗、教学、科研的基础资料,也是医学科学的原始档案材料。在我国社会主义市场经济完善中,人们的法制意识、自我保护意识及维权观念逐步增强,医疗纠纷事件不断发生,那么,病案作为医疗活动中的信息载体,临床医师必须客观、准确、真实、完整及规范的完成病案书写记录,加强病案质量管理,为处理医疗纠纷提供依据,从而保护医患双方的切身利益,对于解决和预防医疗纠纷的发生具有重要的意义。
Medical records are medical records of disease diagnosis and treatment process of the document, which objectively, completely and continuously recorded the patient’s condition changes, diagnosis and treatment, the treatment outcome and the final outcome of the disease, is the medical, teaching, scientific research, basic information is also medical science Original file material. In our socialist market economy, people’s sense of legal system, awareness of self-protection and the concept of safeguarding their rights are gradually strengthened, and medical disputes continue to occur. Therefore, as a medical information carrier, clinicians must be objective, accurate, true and complete And to standardize the record of the completion of the case record, strengthen the quality management of medical records, to provide the basis for the treatment of medical disputes, thereby protecting the immediate interests of both doctors and patients, for the resolution and prevention of medical disputes is of great significance.