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病案是指在诊疗过程中对病人的检验、诊断、治疗和愈后转归等情况的一种医疗记录,它是医疗活动中的重要原始记录文件。病人的治疗、复诊需要使用病案,医生的医学研究需要使用病案,医学生的教学也需要使用病案。病案质量不仅对病人各个时期的治疗起着引导作用,也是对医院形象的反映与体现,所以要加强病案质量管理,提高病案内涵质量。本文探讨了从三个方面提高病案内涵的质量。这三个方面分别为:加强医务人员的责任意识教育,组织医务人员学习相关的法律法规和强化对病案的规范化管理。
A medical record refers to a medical record of the examination, diagnosis, treatment and prognosis of the patient during the medical treatment and treatment. It is an important original record in the medical activity. Patient’s treatment, referral need to use the medical record, the doctor’s medical research needs to use the medical record, the medical student’s teaching also needs to use the medical record. The quality of medical records not only plays a guiding role in the treatment of patients during various periods, but also reflects and embodies the hospital image. Therefore, it is necessary to strengthen the quality management of medical records and improve the quality of medical records. This article explores the quality of medical record connotation in three aspects. These three aspects are: to strengthen medical personnel’s sense of responsibility education, organize medical personnel to study the relevant laws and regulations and strengthen the standardized management of medical records.