目的规范病历书写,保证医疗安全。方法本文通过对缺陷病案的特征进行分析,找出存在的问题,提出改进的措施。结论病案书写的好坏,将直接影响医疗责任的认定。规范病案书写,将有效保护医患双方的合法权益,为医疗安全提供保证。 Purpose To standardize medical records and ensure medical safety. Methods This article analyzes the characteristics of defect medical records, identifies existing problems, and proposes improvements. Conclusion The writing of medical records will directly affect the identification of medical responsibility. Standardizing the writing of medical records will effectively protect the legitimate rights and interests of both doctors and patients and provide guarantees for medical safety.