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通过学习《医疗事故处理条例》和《医疗机构病历管理规定》,分析医院病案管理的现状,提高对病案管理重要性的认识,探索病案管理的对策。医院要有效地防范医疗事故尤其是在“举证倒置”的今天为了更好地防范医疗纠纷,医院证明自己全部医疗活动无过错,除了要严格遵守和落实有关法规、制度、医疗标准、技术常规操作规程外,还要重视对病案资料实行全面、及时、综合的质量控制和管理控制,以促进医院病案管理的系统化、规范化和现代化。
By studying the Regulations for the Treatment of Medical Accidents and the Regulations for the Management of Cases of Medical Institutions, the status quo of medical record management in hospitals is analyzed, the awareness of the importance of case management is improved, and the countermeasures for the management of medical records are explored. Hospitals must effectively prevent medical accidents, especially in the “inverted proofs” today, in order to better prevent medical disputes, the hospital has proved that all its medical activities are not at fault, in addition to strictly abide by and implement relevant laws and regulations, systems, medical standards, and technical routines. Apart from the procedures, we must also attach importance to the implementation of comprehensive, timely, and comprehensive quality control and management control of medical record data to promote systematic, standardized and modernized medical record management in hospitals.