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病历档案是指医务人员在诊疗就诊患者过程中形成的文字、符号、图表、影像、切片等资料的总和,它是患者就医全过程的客观、真实的记录,是治疗和治愈病人的依据。一、病历档案管理中存在的问题一是在一些医院病历档案管理制度不健全,或病历档案制度执行的不好,致使病历档案收集的不全。二是个别医院出于某种目的,有人为修改病历档案的现象,
Medical record refers to the medical staff in the process of diagnosis and treatment of patients formed by the text, symbols, charts, images, slices and other information, it is the patient’s medical treatment objective and true records of the whole process, is the basis for the treatment and cure patients. First, the medical records management problems First, some medical records management system in some hospitals is not perfect, or the implementation of the medical records system is not good, resulting in incomplete medical records collection. Second, some hospitals for some purpose, some people to modify the medical records of the phenomenon,