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病历是医院最常见的文书之一,患者的医疗健康档案记录了患者疾病的发生、发展、转归,进行检查、诊断、治疗等医疗活动过程的同时对采集到的资料也加以归纳、整理、综合分析。而且必须按规定的格式和要求书写。病历既是对临床实践工作做的总结,又是对疾病规律的一种探索及处理医疗纠纷的法律依据,是国家的宝贵财富。病历对医疗、预防、教学、科研、医院管理等都有重要的作用。在医疗纠纷中,它是一把双刃剑,高质量的病历是医务人员的保护伞,反之则会是其最大的敌人。近年来,医院篡改病历的现象比较普遍,尤其是在发生医疗事故之后,更加明显,这样的纠纷也屡见报端。
The medical record is one of the most common instruments in the hospital. The patient’s medical health record records the occurrence, development, prognosis of the patient’s disease, the process of medical activities such as examination, diagnosis and treatment. At the same time, the collected information is also summarized, Comprehensive analysis. And must be written in accordance with the required format and requirements. Medical records not only summarize clinical practice, but also provide a legal basis for exploring the laws of disease and handling medical disputes and a valuable asset for the country. Medical records on medical, prevention, teaching, research, hospital management and so have an important role. In medical disputes, it is a double-edged sword, high-quality medical record is the umbrella of medical staff, and vice versa will be its biggest enemy. In recent years, the phenomenon of tampering with medical records in hospitals has become more common, especially after the medical accidents have occurred. This kind of disputes are also frequently reported.