摘要
目的提高临床医师对病历书写重要性以及在法律风险中意义的认识,提高自我保护意识。方法分析2009年1月1日-12月31日的病历质控记录,对存在缺陷进行统计分析。结果病历缺陷是书写不完整,不能正确地反映病情的变化以及不正确涂改引发病历真实性的争议等。结论严格审查,加强管理,强化病历书写质量意识,提高法律风险意识。
Objective To improve the awareness of physicians on the importance of medical records writing and its role in legal risks in order to enhance self-protection awareness.Methods The quality control records of medical records in 2009 were analyzed,and existing defects were also statistically analyzed.Results The defects in medical records were incomplete writing and incorrect alterations,the former could not correctly reflect the changes of diseases,and the latter induced validity-related debates.Conclusion It is necessary to strictly inspect,strengthen management and intensify the awareness on the writing quality of medical records and legal risks.
出处
《中国病案》
2010年第10期42-43,共2页
Chinese Medical Record
关键词
病历书写
法律风险
防范措施
Medical records writing
Legal Risk
Preventive measure
