病案是患者病史的档案,也是医院进行医疗活动的记录。无论对患者还是医院都具有十分重要的意义。实际中由于多方面的因素,病案书写质量还存在一些问题,如缺少相关病情资料,症状描述不全,诊断与治疗方案不完整。为引起医疗纠纷埋下过错的隐患,由此可能引发赔偿。2001年我院曾发生医疗纠纷5起,其中三起被患方揪住病历书写中存在的问题而质问院方过错,使医院处于尴尬被动 The medical record is a file of patients’ medical history and a record of hospital medical activities. It is of great significance to patients and hospitals. In practice, due to various factors, there are still some problems in the writing quality of medical records, such as lack of relevant disease information, incomplete description of symptoms, and inaccurate diagnosis and treatment plans. In order to cause medical disputes to lay the hidden dangers, it may trigger compensation. In 2001, there were 5 medical disputes in our hospital. Three of them were affected by the problems in the writing of medical records. They questioned the fault of the hospital and left the hospital in a passive state.