病案是医疗全过程的客观记录,反映了医院的管理水平、医疗质量和医师的业务水平;病案具有法律效力,是医疗举证过程的重要证据。病案质量的管理也成了医院一项常抓不懈的重要医疗质量管理的手段之一。手术科室医疗风险较大,加强手术科室的病案管理,现将手术科室病案质控情况回顾分析如下。 Medical records are objective records of the whole process of medical treatment, reflecting the management level of the hospital, the quality of medical services and the professional level of the doctors. The medical records have the legal effect and are the important evidences of the medical proof process. The quality of medical record management has become one of the most important medical quality management tools in hospitals. Surgical departments larger medical risks and strengthen surgical department medical record management, surgical department is now the quality of the case review control as follows.