摘要
目的提高病案质量,防范医疗纠纷。方法从病案缺陷对医疗纠纷的影响、病案在处理医疗纠纷中的重要作用、如何提高病案质量等几方面进行分析。结果病案缺陷可能使病人对诊疗护理的结果产生疑虑而引发纠纷,或使医院在处理医疗纠纷中面临尴尬,甚至无过失的医疗行为可因病案缺陷将承担举证不能的法律责任导致医院的败诉。结论病案质量问题在医院管理方面是一个非常重要的问题,应该引起医院管理者、病案管理人员、医护人员的重视。
Objective To improve the quality of the medical record and prevent thZe medical disputes. Methods To analyze the medical records from angle of the influence of the medical record defects to the medical dispute, the important role of the medical record in processing the medical disputes, and how to improve the medical record quality and so on. Results The defects in the medical record possibly cause the patients to suspect the diagnoses and the nursing, which lead to the disputes, or cause the hospital awkwardly in handling the medical disputes. Furthermore, the medical record defects even cause the hospital losing a lawsuit in no - error medical behaviors because it cannot undertake the legal liability to present evidence. Conclusion The quality of the medical record is a very important in the hospital management. The hospital superintendents, the medical record managers, doctors and nurses all should pay attention to it.
出处
《中国病案》
2008年第6期43-44,共2页
Chinese Medical Record
关键词
病案质量
病案缺陷
医疗纠纷
medical record quality
medical record flaw
medical service dispute
