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近年来关于医疗事故管理规定条文的出台,病案成为了患者及医院能够拿出来的最具说服力的证据。所谓病案是指按规范记录患者疾病表现和诊断治疗情况的档案,一般是由医院的病案管理部门负责保存,形式多样,包括纸质、电子稿等。病案在一定程度上客观地记录了患者的病情和治疗过程,为指导临床治疗方面有借鉴作用。然而在现实生活中,常常会出现患者病案受到污染甚至遗失的情况,尤其是在感染性疾病科病案污染的情况屡见不鲜。倘若病案遭到污染,这会缩短患者的资料保存时间,更为严重的时候会对患者及医生构成健康威胁。因此,寻找出感染性疾病科病案污染的原因,采取积极有效的措施予以防范显得尤为重要。所以,本文从感染性疾病科病案污染的因素、防范措施这两个方面予以综述,具体如下。
In recent years, the provisions of the provisions on the management of medical incidents, the medical record has become the most convincing evidence patients and hospitals can come up with. The so-called medical record refers to record the patient’s disease performance and diagnosis and treatment of the file according to norms, generally by the hospital’s medical record management department is responsible for the preservation of various forms, including paper, electronic draft. To a certain extent, the medical record objectively records the patient’s condition and the course of treatment, and serves as a reference for guiding the clinical treatment. However, in real life, it is not uncommon for patients’ records to be contaminated or even lost, especially in cases of infectious diseases. If the medical record is polluted, this will shorten the patient’s data retention time and, in more serious cases, pose a health threat to the patient and the doctor. Therefore, to find out the cause of infectious disease department of case pollution, take active and effective measures to prevent it is particularly important. Therefore, this article from infectious disease disease case pollution factors, preventive measures are summarized in these two aspects, as follows.