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病案是涉及医疗纠纷及诉讼的重要证据,在病案管理中,必须规范病案书写提高病案质量,确保病案的完整归档和妥善保管;医务人员和病案管理人员应定期的进行业务学习和法制教育,强化法律意识,建立完善有效的病案管理机制。只有从病案书写到病案归档全过程进行严格控制管理,才能最大限度地减少和防范医疗纠纷,确保医院医疗工作正常运行。
Medical records and medical litigation is an important evidence involved in the medical records management, standardized medical records must be written to improve the quality of medical records to ensure the complete filing of medical records and safekeeping; medical staff and medical record management staff should conduct regular business education and legal education, strengthen Legal awareness, establish a sound and effective medical record management mechanism. Only from the medical record to the entire process of medical records to strictly control the management, in order to minimize and prevent medical disputes, to ensure the normal operation of hospital medical work.