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病历书写是临床医生的一项基本功。其书写质量的优劣,不仅体现了医护人员的技术水平、敬业态度,同时也是评价一个医院的医疗质量和管理水平的重要依据,特别是修订后的《医疗事故处理条例》中规定,当病人及其家属与医院发生医疗纠纷时可以向医院要求复印病案。这充分说明病案在处理医疗纠纷中的重要作用,同时也对病历书写提出了更高的要求。现根据《江苏省病历书写规范》要求,随机抽查我院2001年上半年病案1342份,分析如下:
Medical records writing is a basic skill of clinicians. The merits of its writing quality, not only reflects the technical level of medical staff, dedication, but also to evaluate a hospital’s medical quality and management of an important basis, in particular the revised “Medical Accident Disposal Ordinance” provides that when the patient And their families and hospitals in medical disputes can request a copy of the hospital case. This fully shows that medical records play an important role in handling medical disputes and also sets higher demands on the writing of medical records. Is based on “medical records writing in Jiangsu Province” requirements, randomly selected in our hospital in the first half of 2001, a record of 1342 cases, as follows: