《医疗事故处理条例》已于2002年9月1日起实行,卫生部和国家中医药管理局为配合其实施,下发了一系列配套文件,《病历书写基本规范(试行)》就是其中之一。 由于《医疗事故处理条例》明确规定相关护理文件作为病人可以复印和复制的资料,是进行医疗事故技术鉴定的重要依据,所以在实施过程中,临床上普遍反响较大,争议较多。 The Regulations on the Handling of Medical Accidents came into force on September 1, 2002. A series of supporting documents were issued by the Ministry of Health and the State Administration of Traditional Chinese Medicine in support of its implementation. The basic norms of medical record writing (for Trial Implementation) one. Because the “Medical Malpractice Ordinance” clearly stipulates that the relevant nursing documents as patients can copy and copy the information is an important basis for technical identification of medical malpractice, so in the implementation process, the clinical widespread response, controversial.