从新法规谈病历书写的完善  

Perfection of Medical Record with the Perspective of New Laws and Regulations

作　　者：徐丽芳[1] 郑逸飞[2] 刘灿均[1] 陶春牡[1] 

机构地区：[1]江苏省靖江市人民医院,靖江214500 [2]南京医科大学,南京210029

出　　处：《解放军医院管理杂志》2011年第5期482-484,共3页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：随着病历在医疗诉讼中的作用越来越大,病历书写的质量日渐受到重视。本文从新出台的《侵权责任法》和《病历书写规范》出发,分析病历书写的要点、重点和注意事项,旨在加强医疗文书的规范化,提高病历书写的质量,在对患者负责的同时加强医务工作者的自我保护。As the medical record becomes increasingly important in the medical malpractice case,more and more attentions are paid on the quality of the medical.The article proceeds from the content of Tort Liability Law and Guideline of Medical Record,to analyze the principle,details and cautions of medical record,and improve the quality of medical record and protect both the patient and medical staff.

关 键 词：病历 侵权责任法 病历书写规范 

分 类 号：R197.32[医药卫生—卫生事业管理]