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目的:为临床药历书写和药历规范管理提供参考。方法:分析药历与病历的关系、药历与患者权利的关系、药历的证据作用、药历书写的责任风险等相关法律问题,并提出对策和建议。结果与结论:药历与病历具有相同的法律属性,具有法律上的证据作用,同时,书写药历可能有一定的责任风险。应当提高对药历的法律意义的认识,提高书写药历的实际操作能力,并加强对药历的管理。
Objective: To provide a reference for the writing of clinical medical records and the standard management of medical records. Methods: To analyze the relationship between medical records and medical records, the relationship between medical records and patients’ rights, the evidence of medical records and the liability risks of medical records writing, and to put forward countermeasures and suggestions. RESULTS AND CONCLUSION: The medical records and medical records have the same legal attributes and have legal evidence. At the same time, writing the medical records may have a certain liability risk. It is necessary to raise awareness of the legal significance of medical records, enhance the practical ability to write medical records, and strengthen the management of medical records.