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机构地区:[1]天津塘沽第五中心医院病案室 [2]天津经济技术开发区医院病案室
出 处:《中国病案》2009年第4期25-26,共2页Chinese Medical Record
摘 要:病案是推定医疗过错及医疗事故判断的重要法律依据,因此病案质量十分重要,病历质量管理应依法书写、依法管理。病历书写必须客观、真实、准确完整;恪守病历书写的资格与权限,符合医疗行政部门的有关规定要求;并在规定的时间内完成;病历书写的内容也必须符合法律法规的规定;重视患者的知情权和知情同意书的签署。Since case history is a vital legal evidence for medical mistake and medical accident, the quality of it is quite important. In the management of medical record quality, the writing and management of medical record should be follow by law. The writing of medical record which requires finished on time should be objective, true, and complete; the qualification and the authority of medical records writing should be in accordance with the related regulations of medical administrative section; the content should be in line with the laws and regulations. Patients' right to know and the subscription of informed consent form should be regarded.
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