病历与病案的初步探讨  

Preliminary Discussion on Medical Records and Case History

作　　者：黄小东[1] 葛金玲[1] 王丽清[1] 

机构地区：[1]广州中医药大学第一附属医院质控科,广州510000

出　　处：《中国中医药现代远程教育》2016年第18期31-33,共3页Chinese Medicine Modern Distance Education of China

摘　　要：目的探讨病历、病案的联系与区别,使读者能够正确的认识病历、病案的重要性。方法结合原国家卫生部、国家卫生与计划生育委员会的相关规定、历史文献进行分析。结论病历是医疗活动中的阶段性记录,具有动态性、可修改性、开放性,在医疗质量与医疗安全的监控及法律证据中的价值更明显;病案是医疗活动结束后的完整、系统的归档记录,具有终结性、确定性、封闭性,在医疗教学、科研、统计及社会服务等方面的价值更突出。Objective To study the contact and differences of the medical records and case history, so that readers can correct learn the importance of them. Methods The analysis was carried out by the historical literature and the relevant provisions of the Ministry of Health and the National Health and Family Planning Commission. Conclusion The medical records is a immediate recording in the medical activities, with dynamically, editable, openly and more valuable in the legal evidence, monitoring of medical quality and medical safety. The case history is a complete, systematical archived record after the medical activities, with finally, certainly, c10s.edly, more valuable in terms of medical teaching, research, statistics and social services.

关 键 词：病历 病案 医疗质量 医疗安全 医院管理 

分 类 号：R197.323[医药卫生—卫生事业管理]