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目的基于医院病案管理现状,探讨规范病案的制作和管理,进一步减少医疗纠纷。方法解读《侵权责任法》与病案相关的法律条文,对案例进行分析。结果手写病历和电子病案均存在管理缺陷,易出现书写不规范、记录不及时、项目不完整、内容失真等问题。结论医疗机构能够在纠纷发生时提供真实完整的病案资料,有利于对医疗损害责任的成立与否作出认定,降低败诉风险。
Objective Based on the current situation of hospital medical record management, explore the production and management of standardized medical record and further reduce medical disputes. Methods To interpret the legal provisions of Tort Liability Law related to medical records and analyze the cases. Results handwritten medical records and electronic medical records are defective management, prone to writing is not standardized, the record is not timely, the project is incomplete, the contents of the distortion and other issues. Conclusion Medical institutions can provide true and complete medical record information when the dispute occurs, which is helpful to identify the liability of medical damage or not and reduce the risk of losing the lawsuit.