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随着《医疗事故处理条例》的颁布实施,医疗纠纷也相应增多,加之病人有知情同意权及复印客观病历的权利,使病历文书的书写越来越重要,要求越来越高,各种记录必须客观、及时、准确、全面、严肃认真。这对病案质量提出了严峻的挑战及更高的要求。那么,如何搞好病案质量控制,使之更好地为医疗机构服务,尽量避免医疗纠纷,严禁医疗事故的发生具有重要意义。现将我院病案质量控制中发现的几个问题及对应处理措施简介如下,仅供参考。
With the promulgation and implementation of the “Medical Accident Handling Regulations,” medical disputes have also increased accordingly. In addition, patients have the right to informed consent and the right to copy objective medical records. This makes the writing of medical records more and more important and requires more and more records. Must be objective, timely, accurate, comprehensive, and serious. This poses severe challenges and higher requirements for the quality of medical records. Then, how to do a good job in the quality control of medical records so that it can better serve medical institutions, try to avoid medical disputes, and it is strictly forbidden that the occurrence of medical accidents is of great significance. Several problems found in the quality control of medical records in our hospital and the corresponding treatment measures are described below. They are for reference only.