做好病案管理工作的医学伦理原则与对策  

Ethical Principles and Countermeasures for Medical Record Management

作　　者：刘晓青[1] 刘宏颀[1] 刘晓雷[2] 

机构地区：[1]第四军医大学马克思主义与人文学院,陕西西安710032 [2]第四军医大学西京医院医教部,陕西西安710032

出　　处：《中国医学伦理学》2015年第2期220-222,共3页Chinese Medical Ethics

摘　　要：病案管理中应当遵循知情同意、自主、保密、有利于患者、公正等医学伦理学的基本原则,落实在具体工作中,体现为程序规范、服务适度、病案完整。为进一步加强病案管理,应当规范病案书写,健全病案管理监督机制,加强对医务人员的医德医风教育,同时,增强医务人员的法律意识。Medical record management should follow the medical ethics principles such as the mIormeO con- sent, independence, confidentiality, in favour of patients, justice and so on. The implementation of these princi- ples requires program specification, service moderate principle and medical record integrity. The authors also put forward the countermeasures to further improve the medical record management, it should standardize the medical record writing, establish and improve the medical record supervision system, strengthen the education of medical ethics of medical personnel, at the same time, strengthen the legal consciousness of medical staff.

关 键 词：病案管理 医学伦理学 知情同意 患者隐私 医德医风 

分 类 号：R-052[医药卫生]