提高病历书写质量 防范医患纠纷  

Improving the Quality of Medical Records, to Keep Medical Disputes away

作　　者：张存仁[1] 董海军[1] 马汝怀[1] 

机构地区：[1]陕西省榆林市第一医院

出　　处：《中国病案》2007年第8期17-18,共2页Chinese Medical Record

摘　　要：随着公众法律意识的不断增强,《医疗事故处理条例》的实施和医疗纠纷中的举证倒置,发生医疗纠纷要向司法机关提供病案,病案成为处理医患纠纷的直接证据。通过对病案质量存在问题及原因的分析,阐述了医院要重视病案书写质量,加强病案规范化管理,防范医疗纠纷,保障医疗安全。With the unceasing enhancement of people＇s law consciousness, the implementation of The Regulations of Dealing with Medical Accidents and inversion of onus probandi in medical disputes, the medical records have to be provided to the judicial organ and they have become the direct evidence when processing medical disputes. By analyzing the existing problems in the medical records and the reasons why these problems exit, this paper presents that medical records should be written correctly and carefully, and the standardization of medical records management should be strengthened, so that medical disputes will be prevented and medical service security will be safeguarded.

关 键 词：病案质量 医疗纠纷 防范 对策 

分 类 号：R-051[医药卫生]