依法书写和管理病案

Write and Manage Medical Records Based on Law to improve its Quality

目的探讨如何依法书写和管理病案,提高病案质量。方法通过对住院病案质量检查,结合文献查阅法,对病案书写质量存在的问题和病案管理质量中存在问题、影响因素和对策进行归纳、分析。结果归纳出病案质量存在的问题和法律法规要求,总结了影响病案质量的因素,提出具体对策。结论通过共同努力,依法管理病案,病案质量一定会得到保证和提高。

Objective To explore how to write and manage medical records in accordance with law for improvement of the quality of medical records. Methods The problems,influencing factors and countermeasures existed in the writing quality of case history and management quality of medical records were summarized and analyzed. Results The problems existed in writing of medical records were inducted,summarized,and analyzed to raise special countermeasures. Conclusion The writers of case history write it based on the law,which can ensure and improve the quality of medical records.