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目的提高医务人员的法制意识,保证病案的证据学证明力。方法通过律师查房,从法律证据学角度对在院病人住院病历形成过程中存在的问题进行检查,现场进行讨论、反馈信息、及时改进。结果对病案形成过程中的客观、真实、及时、准确、完整性,主干医疗工作制度执行力度,知情告知,在院病人住院病历保管的问题及解决对策进行了剖析。结论医院及其医务人员只有严格执行法律法规,把握医疗文书形成各个环节,保证病历质量并妥善保管,才能提高医疗质量、堵塞漏洞、保证医疗安全。
Objective To improve the legal awareness of medical staff and ensure the evidentiary power of medical records. Methods Through the lawyer’s rounds, the problems existing in the formation of the inpatient history of the hospital were examined from the perspective of legal evidence, and discussions, feedback, and timely improvement were conducted on the spot. As a result, the objective, truthfulness, timeliness, accuracy, completeness of the medical record formation process, the implementation of the main medical work system, the informed notification, the problems in the hospital patient record keeping and the countermeasures were analyzed. Conclusion Hospitals and their medical staff can only improve the quality of medical treatment, plug loopholes, and ensure medical safety by strictly implementing laws and regulations, grasping all aspects of medical documents, ensuring the quality of medical records, and keeping them properly.