病案是医护人员在临床实践活动中,对病人的检查、诊断、治疗及护理过程中所形成的详细记录。随着医院改革的深入和人们法律意识的不断提高,病案不仅在临床、科研、教学中起着广泛的作用,而且是医疗纠纷、医疗保险、交通肇事、伤残鉴定、司法鉴定的原始凭据。 目前,滞后的医疗管理现状与高速发展的医学技术已不相适应,只抓收入,忽视管理;只管手术,不求病历质量的现象普遍存在。因病历质量缺陷引发的医疗纠纷屡屡发生,它冲击了正常运转。现就病历质量缺陷引发医疗纠纷的因素加以分析,以便 The medical record is a detailed record of the examination, diagnosis, treatment and care of the patient during the clinical practice activities of the medical staff. With the deepening of hospital reform and the continuous improvement of people’s legal awareness, medical records not only play a wide role in clinical, scientific research, and teaching, but also serve as original credentials for medical disputes, medical insurance, traffic accidents, disability appraisals, and forensic appraisals. At present, the current situation of lagging medical management is no longer compatible with the rapid development of medical technology. It only focuses on income and neglects management; the mere existence of surgery and the quality of medical records are common. Medical disputes caused by medical record quality defects have occurred frequently and it has impacted normal operations. We will analyze the factors that cause medical disputes due to medical record quality defects so that