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医疗事故处理条例的颁布和实施,使病历书写引起的医疗纠纷,成为医疗纠纷的一个新热点。在目前的医疗工作中,很多医师仍对病历的书写重视不够,对病历书写法律证据作用认识不足,缺乏自我保护意识,败诉并不少见。 病历引起纠纷的常见原因有:现病史乱写不真实;手术和麻醉同意书涂改;病历中时间记录错误;医疗制度未落实;医嘱用药不符等。预防措施:加强病历书写的法律意识;规范书写病历各项内容,完善病历质量监控系统。 病历是病人住院疾病诊治过程的全面记录,是医疗行为的唯一载体,具有原始证据作用,有重要
The promulgation and implementation of medical malpractice regulations have made medical disputes caused by the writing of medical records a new hot spot for medical disputes. In the current medical work, many doctors still do not pay enough attention to the writing of medical records, they do not fully understand the role of writing legal evidence in medical records, they lack awareness of self-protection, and it is not uncommon to lose. The common causes of disputes in medical records are: the current history of illness is not scribbled; the consent form for surgery and anesthesia is altered; the time records in the medical records are incorrect; the medical system has not been implemented; Preventive measures: Strengthen the legal awareness of medical records; standardize the contents of written medical records, and improve the medical record quality monitoring system. The medical record is a comprehensive record of the patient’s inpatient disease diagnosis and treatment process, is the only carrier of medical behavior, has the role of the original evidence, there is an important