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病案是真实记录医务人员对患者诊疗全过程的原始信息资源载体,其实用价值已远超出了传统的概念。它不仅仅是医院的宝贵财富,它已成为可靠的法律依据及保险理赔的重要证据,并愈来愈受到社会各阶层的关注。特别在当今医疗机构服务质量问题成为人们饭前茶后的议论焦点时,病案更显示出存在的重要价值。它实际上已成为一种检验某医疗机构综合实力的标准之一。因此,病案质量问题也越来越得到医院管理层及广大医务人员的重视,从而使病案管理人员感到自己的责任重大。近几年,笔者通过与同行接触了解及做了一些调查发现,涂改、伪造病案等违法现象,在一些医院时有发生,甚至一些地区还较为严重,使病案的真实性、完整性可信度下降,突出表现在以下几点:
The medical record is the original information resource carrier that records medical personnel’s entire process of patient’s diagnosis and treatment, and its practical value has far exceeded the traditional concept. It is not only a valuable asset of the hospital. It has become a reliable legal basis and an important evidence for insurance claims, and it has received increasing attention from all walks of life. Especially in today’s medical institutions, the quality of service has become the focus of discussion after the pre-meal tea, the medical record shows the important value of existence. It has actually become one of the criteria for testing the overall strength of a medical institution. As a result, the quality of medical records has also received more and more attention from hospital management and medical personnel, which has made medical record managers feel that their responsibilities are significant. In recent years, the author has known and made some investigations through contact with peers. It has been found that violations of the law, such as altering or falsifying medical records, have occurred in some hospitals, even in some regions, and have made the medical records more truthful and complete. The decline is prominent in the following points: