外科围手术期病历书写存在问题及对策

The problem in writing perioperative medical records and the countermeasure

病案是医疗活动真实的历史记载,是法定的医学文件,具有法律效力。写好外科围手术期的病历,是杜绝因病案记录存在缺陷引发医疗纠纷的关键,是外科病历管理的重要内容。

Medical records is the real history of medication for a patient, the legal document of medical work of a group medical staff, An authentic record about the perioperative is the key protecting proof from medical dispute,it is also the main aspect of medical record supervisement.