许多医务人员对病案在医疗纠纷中的地位、作用和责任等了解不多,更没有从法律的角度加以认识和重视。在提供医疗、健康保险、伤残和病退的评定、医疗事故的鉴定及法律纠纷的调解等多方面的工作中,都需要以病案作为依据。精神科病历是检查和衡量医疗质量的重要资料,而且在法律上还有着不容忽视的重要性。因此,提高病案质量,加强病案制度化、规范化和法制化的管理,已成为防范医疗过失和纠纷的一个重要环节。 Many medical personnel do not know much about the status, role and responsibilities of medical records in medical disputes, and they do not understand and value them from the legal point of view. In providing medical, health insurance, assessment of disability and sickness, identification of medical accidents and mediation of legal disputes, etc., medical records are required as a basis. Psychiatric medical records are important data for checking and measuring the quality of medical care, and there is also a legal importance that cannot be ignored. Therefore, improving the quality of medical records and strengthening the institutionalized, standardized and legalized management of medical records has become an important link in preventing medical negligence and disputes.