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目的提高病案质量,防范医疗风险。方法分析病案缺陷的表现形式,病案在防范医疗风险中的作用,及如何提高病案质量的几种措施。结果医疗风险增加是现代医学发展的必然,问题病案可使原本无医疗差错、事故的医务人员陷于医疗危机,使医院在处理医患纠纷中处于不利的地位。结论病案质量体现医疗质量和技术水平,在医疗风险事件中起重要作用,医护人员应重视病历书写,医院管理者应重视病案质量管理。
Objective To improve medical record quality and prevent medical risks. Methods To analyze the manifestations of medical record defects, the role of medical records in preventing medical risks, and how to improve medical record quality. Results The increase of medical risk is inevitable for the development of modern medicine. The medical record of the problem can cause the medical staff who were originally without medical errors and accidents to fall into the medical crisis, which makes the hospital at a disadvantage in the treatment of disputes between doctors and patients. Conclusion The quality of medical records reflects the medical quality and technical level, which play an important role in medical risk events. Medical staff should pay attention to the writing of medical records. Hospital administrators should pay attention to the quality management of medical records.