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病案管理是现代医疗质量管理的重要组成部分,医学伦理原则体现在病案管理的各个环节。病案管理要求各项病案管理操作满足符合患者利益、保护患者隐私权、尊重患者知情权及遵守法律等医学伦理要求。医学伦理贯穿于病案管理的始末,包括病案书写中的住院问诊、临床检查、诊疗计划、手术治疗、日常查房,病案归档中的纸质病案和电子病案的收集、整理、汇总和保存等,病案提供中的患者或第三方对病案资料的获取、临床或科研人员对病案资料的获取等方面。
Medical record management is an important part of modern medical quality management. Medical ethics principles are reflected in all aspects of medical record management. Medical records management requires that all medical records management practices meet medical ethical requirements that are in the interests of the patient, protecting the patient’s privacy, respecting the patient’s right to information and compliance with the law. Medical ethics runs through the entire history of medical record management, including inpatient medical examination, clinical examination, diagnosis and treatment plans, surgical treatment, daily rounds of examination, collection of paper medical records and electronic medical records in medical record collection, collation, compilation and preservation, etc. , The patient in the medical records or third party access to medical records, clinical or scientific research staff access to medical records and so on.