病历书写质量规范对策  

Countermeasures for Quality Standard of Medical Record Writing

作　　者：田胜男[1] 王晓路[2] 茹丽娜 王子宇 时保军[2] TIAN Shengnan;WANG Xiaolu;RU Lina;WANG Ziyu;SHI Baojun(Department of Policies and Regulations,Second Hospital of Hebei Medical University,Shijiazhuang 050000;Hospital Office,Second Hospital of Hebei Medical University,Shijiazhuang 050000)

机构地区：[1]河北医科大学第二医院政策法规处,石家庄050000 [2]河北医科大学第二医院院办,石家庄050000

出　　处：《解放军医院管理杂志》2020年第11期1052-1053,1064,共3页Hospital Administration Journal of Chinese People's Liberation Army

基　　金：2017年度河北省社会科学发展研究课题:202例医疗损害审判案件的研究分析(201710120924)。

摘　　要：医疗病历资料不仅是医学教学、科研的重要依据,也是公安、司法、保险、鉴定机构等部门工作的重要依据之一。病历的真实性是各部门决定是否采纳病历作为依据的核心。文章结合"患者要求更改主诉内容"的审判案例,阐述病历书写的客观真实原则,警示医务人员违规书写、修改病历可能承担的法律责任,并给出病历管理的相应建议,为防范相关风险提供参考。Medical record data is not only an important basis for medical teaching and scientific research,but also an important basis for the work of public security,judicial,insurance,appraisal institutions and other departments.The authenticity of medical records is the core of the decision of each department whether to adopt medical records as the basis.Based on a trial case of"the patient requests to change the content of the main complaint",this paper further expounded the objective and true principle of medical record writing,warned the medical staff of possible legal responsibility for writing and modifying the medical record in violation of regulations,and gave corresponding suggestions for medical record management,so as to provide reference for the prevention of relevant risks.

关 键 词：病历资料 客观真实 法律责任 管理 

分 类 号：R197.32[医药卫生—卫生事业管理]