病历书写质量在防范医疗纠纷中的作用  

The Effect of Medical Records Writing Quality in Preventing Medical Disputes

作　　者：隗燕莉[1] 

机构地区：[1]首都医科大学燕京医学院附属良乡医院医务科

出　　处：《中国病案》2012年第2期17-18,共2页Chinese Medical Record

摘　　要：目的规范病历书写,提高病历书写质量,防范医疗纠纷,探讨病案在医疗纠纷中的法律作用。方法将本院2008年-2009年173例医疗纠纷的病案进行整理分析找出存在的问题。结果 2008年-2009年医疗纠纷,涉及到病案书写有问题的病历12例(占6.9%),病历书写质量存在缺陷。结论规范病历书写质量管理,加强病案质量控制和病案环节管理,使病案管理的环节科学和规范化,是有效避免或降低医疗风险的关键。Objective To standardized medical records writing,improve the writing quality,prevent medical disputes,discuss legal effect of medical record in medical disputes.Methods Analyzing 173 cases of medical disputes records and finding out existing problems from them from 2008 to 2009.Results Twelve medical records have writing problems（6.9%） from 2008 to 2009.Conclusion Strengthening medical records writing quality management,medical record quality control and medical record link management,making medical records management link science and standardization are the key of avoiding or reducing the medical risks.

关 键 词：病历书写 病案管理 医疗纠纷 

分 类 号：R197.3[医药卫生—卫生事业管理]