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病案是医务人员对患者进行问诊、诊断、治疗、护理等医疗活动中所做的诊疗记录,包括某些图表和影像报告等材料,并经综合、分析、整理后归档的记录。是医院临床医、教、研的宝贵档案和信息资源,它对评价医院的医疗技术水平、管理水平、经济效益和社会效益起着非常重要的作用。随着2002年9月1日我国新《医疗事故处理条例》的颁布实施,如何统一规范病案管理,有效规避医疗纠纷,已成为医院和广大医务人员及病案管理工作者面临的一个新的迫切需要解决的重要课题。笔者依据现实状态和所见所闻,就当前病案管理中存在的问题及对策谈点粗浅认识。
The medical record is the records of the medical personnel’s records of medical consultations, diagnosis, treatment, nursing and other medical activities performed by the medical staff, including certain charts and video reports, and records that have been consolidated, analyzed, and archived. It is a valuable archive and information resource for clinical medicine, teaching and research in the hospital. It plays an important role in evaluating hospital medical technology level, management level, economic benefits and social benefits. With the promulgation and implementation of China’s new “Medical Accident Handling Regulations” on September 1, 2002, how to unify and standardize the management of medical records and effectively circumvent medical disputes has become a new urgent need for hospitals, medical personnel and medical records management workers. The important issue to solve. Based on the actual state and what I have seen and heard, the author discusses the problems and countermeasures in the management of current medical records.