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病历是医务人员在对患者的诊疗活动中所形成的资料总和,是医疗活动的真实记录,是一种医学技术档案,是医疗纠纷处理中重要的法律文书。一份高质量的病历不仅要符合国家卫生行政部门的相关要求,更要真实客观地记载患者的诊疗过程。运行病历的质量管理一直是环节质量管理中不可缺?
The medical record is the summation of the information formed by medical staff in the diagnosis and treatment of patients and is a true record of medical activities. It is a medical technical file and an important legal document in the handling of medical disputes. A high-quality medical records not only to meet the relevant requirements of the national health administration, but also a true and objective record of the patient’s treatment process. The quality of medical records management has always been an integral part of quality management?