病历质量缺陷案例分析  

Analysis of Defects in Medical Records

作　　者：白家琪[1] 张红宇[1] 李作兵[1] 顾跃静[1] 王全虹[1] 张洁[1] 李晓杨[1] 

机构地区：[1]首都医科大学宣武医院,北京100053

出　　处：《中国卫生质量管理》2017年第1期37-38,共2页Chinese Health Quality Management

摘　　要：病历不仅是诊疗经过的客观记载,同时也是医疗纠纷诉讼过程中的重要证据。通过分析纠纷案例,归纳易被法院或鉴定机构认定的病历缺陷,讨论其原因及所带来的法律后果,并提出提高病历质量的改进建议。Medical record is not only the carrier of the diagnosis and treatment, but also the important evidence in the process of medical dispute lawsuit. By analyzing the dispute case, to inductive medical defects recognized by court or appraisal agencies, discuss the reasons and legal consequences, and put forward suggestions of improving the quality of medical records.

关 键 词：纠纷 诉讼 鉴定 病历 缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]