病案是医院的宝贵资料,涉及面广,它不仅在医疗、科研、教学、统计、医院管理过程中起到重要作用,而且在医疗保险、伤残鉴定、交通肇事、医疗纠纷、法律诉讼中具有重要的法律效力,协和医院“三大宝”之首就是病案,由此可见,做好病案管理工作显得极为重要。现就病案管理过程中容易出现的问题提出相应对策。 The medical record is a valuable resource for the hospital. It covers a wide range of fields. It not only plays an important role in the medical, scientific research, teaching, statistics, hospital management, but also in medical insurance, disability identification, traffic accidents, medical disputes, and legal proceedings. With important legal effects, the first place in the “Three Great Treasures” of the Union Hospital is the medical record. This shows that it is extremely important to do well in the management of medical records. Now we propose corresponding countermeasures for problems that may arise during the management of medical records.