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病案包括门诊病历和住院病历两部分,主要包括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,可以详实记录患者的疾病表现及诊疗过程,是医务人员在医疗活动中直接形成的具有法律效力的文书,也是处理医疗纠纷的重要依据。一、优质的病案可以防范医疗纠纷1.案例刘某,因阵发性胸疼1个月,加重2天,于2010年6月4日收住我院心内科。入院诊断为不稳定性心绞痛。当
Medical records, including medical records and outpatient medical records in two parts, including medical personnel in the medical activities in the process of forming the text, symbols, charts, images, slices, etc., can be a detailed record of the patient’s disease performance and treatment process, medical staff in the medical activities The directly formed legally binding instrument is also an important basis for handling medical disputes. First, high-quality medical records to prevent disputes 1. Case Liu, paroxysmal chest pain for 1 month, increased 2 days, on June 4, 2010 admitted to our hospital cardiology. Admission was diagnosed as unstable angina. when