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病历从微观角度讲,是患者诊疗过程的真实记录,是具有法律效用的医疗文书;从宏观角度看,病历质量反映了医院的医疗服务水平,体现了医疗质量管理的品质。病历质量管理是医疗质量管理的基础环节,以提高病历质量管理水平为起点,不断完善医院管理的各个环节,对改善医疗服务品质,促进医院持续健康发展具有举足轻重的作
From the microscopic point of view, the medical record is a true record of the patient’s diagnosis and treatment process and is a legally effective medical instrument. From a macro perspective, the medical record quality reflects the medical service level of the hospital and reflects the quality of medical quality management. Medical records quality management is the basic part of medical quality management, in order to improve the quality of medical records as a starting point, and constantly improve all aspects of hospital management, to improve the quality of medical services and promote the sustained and healthy development of the hospital has played a decisive role