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规范病案表格是提高病案质量和病案法律效力的有力保障。病案表格内容、格式和纸张规格直接影响病案法律效力和病案美观。《黑龙江省病历书写规范》对全省病案表格的内容、格式与纸张大小作出明确要求。规范和统一病案表格,使住院病案外表更加美观,格式更加规范。方便患者、司法机关和保险机构对病案的利用。同时为推动医院信息化实施电子病案打下基础。
Standardizing the medical record form is a powerful guarantee for improving the quality of the medical record and the legal effect of the medical record. The form, format and paper format of the medical record directly affect the legal validity of the medical record and the beautiful medical record. “Heilongjiang Province record writing norms” on the province’s medical records form content, format and paper size to make explicit requirements. To standardize and unite the medical record forms so as to make the appearance of inpatient medical records more beautiful and the format more standardized. Access to medical records is facilitated by patients, the judiciary and insurance agencies. At the same time to promote the hospital information technology to lay the foundation for electronic medical records.