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病案是医疗、教学、科研工作的重要信息资源,是医疗工作中的原始记录和宝贵的历史资料,也是判定法律责任的依据。病案管理作为医院管理的重要内容,直接反映医院的管理水平和技术水平,提高病案管理水平,对促进临床医、教、研的发展具有十分重要的意义。因此,探讨和研究病案管理方法,提高管理水平,提高病案管理人员整体素质,促进医院医疗质量的提高与发展有着十分重要的意义。 一、病案工作的现状。 病案书写质量上存在的问题。
The medical record is an important information resource for medical treatment, teaching, and research work. It is the original record and valuable historical data in the medical work. It is also the basis for determining legal liability. As an important content of hospital management, medical record management directly reflects the hospital’s management level and technical level, and improves the level of medical record management, which is of great significance for promoting the development of clinical medicine, education, and research. Therefore, it is of great significance to explore and study medical record management methods, improve management level, improve the overall quality of medical record management personnel, and promote the improvement and development of hospital medical quality. First, the status quo of medical work. Problems with the writing quality of medical records.