区分主客观病历管理的弊端分析及修改建议  

Deficiency Analysis and Modification Proposals for Management of Subjective and Objective Medical Record

作　　者：袁伟伟[1] 旋妮玲[1] 韩永智[1] 焦雅辉 

机构地区：[1]广东省人民医院.广东省医学科学院,广东广州510080 [2]国家卫生和计划生育委员会医政医管局,北京100044

出　　处：《中国医院管理》2013年第10期27-28,共2页Chinese Hospital Management

摘　　要：目前我国将病历划分为主观和客观部分进行管理,限制患者查阅和复制主观病历资料。针对我国现行的病历管理区分为主客观病历的现状,对区分主客观病历在临床操作中的困境、存在的弊端进行分析。通过探讨病历的本质、用途,从有利于保护病人知情权和推动医学进步的角度,对病历管理规定提出了修改建议。Aiming at the clinical practice predicament caused by current medical record management in China, the deficiency of classified management of subjective and objective medical record is analyzed. According to the research data from health management institute, the article discussed the function of medical record, and proposes the modification suggestions, based on the principle of protecting patients＇ knowing right to propose the rectified suggestions for record management regulation.

关 键 词：病历 管理 医院 

分 类 号：R197.3[医药卫生—卫生事业管理]