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随着2002年4月1日开始实行的“举证责任倒置”,以及9月1日《医疗事故处理条例》的正式实施,病案管理工作在各级医疗机构中的地位和作用显得尤为重要和突出,同时也引起了各层医疗机构领导的高度重视。病案管理是医院科学化管理的重要组成部分,它包括了病案的形成、收集、整理、鉴定、保存、利用、质量检查、统计等。其中病案回收环节中的一些问题在现阶段明显突出。由于病案在医疗责任举证的过程中起着举足轻重、无可替代的证据作用,其内含的病案内容(包括病案的质量和数
With the implementation of the “inversion of the burden of proof” that began on April 1, 2002, and the official implementation of the “Regulations on the Handling of Medical Accidents” on September 1, the status and role of medical record management in medical institutions at all levels is particularly important and prominent. At the same time, it has also attracted the attention of leaders of medical institutions at all levels. Medical record management is an important part of the scientific management of hospitals. It includes the formation, collection, sorting, identification, preservation, utilization, quality inspection, and statistics of medical records. Some of the problems in the recovery of medical records are clearly highlighted at this stage. As the medical record plays a pivotal and irreplaceable role in the proof of medical responsibility, the content of the medical record (including the quality and number of medical records)