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病案是医学知识和经验的宝库,是医学的备忘录,是依据医学理论写下的科学文件。它不仅在医疗、科研、教学、医疗统计的过程中有重要作用,也是处理医疗纠纷、伤残鉴定、健康保险、重症评定及交通事故、司法办案等的法律依据。既然病案为法律服务,就必须从法律的角度去管理病案。在病历形成和病案管理中,我们必须遵循一抓基础、二重环节、三保质量的原则,依法治档,只有这样才能使医务人员规范自己的行为,有效杜绝不良现象,使病案成为重要的法律依据。
A medical record is a treasure trove of medical knowledge and experience, a medical memo, and a scientific document written on the basis of medical theory. It not only plays an important role in medical treatment, scientific research, teaching and medical statistics, but also serves as the legal basis for handling medical disputes, disability identification, health insurance, critical assessment and accident, judicial handling and so on. Since the medical record for the legal services, we must manage the medical record from the legal point of view. In medical record formation and medical record management, we must follow the principle of grasping the foundation, the double links and the quality of the three guarantees and administering the files according to the law. Only in this way can the medical personnel regulate their own behaviors, effectively eliminate the undesirable phenomena and make the medical record an important law in accordance with.