从法律角度完善病案管理

Perfection of Medical Records Management from Legal Angle

病案作为医疗诉讼中的书证被提升到重要的地位,医院要从法律角度出发,依法完善病案管理,保障病案的证据价值。教育医务人员提高病案法律法规意识,如实准确书写病案。医务人员要严格控制医疗文书形成各个环节,加强运行病历的管理,保证病案质量,加强病案信息的安全,发挥其应有的作用。病案科要落实各项病案管理制度,确保工作流程通畅,保证病案资料的完整性和病案利用的及时性,保障医疗安全,防范医疗纠纷,维护医院,避免巨大的损失和风险。

As evidence in medical lawsuit, medical records have been improved to important status. From legal angle, hospital should perfect med- ical records management by law and make sure the evidence value of medical records. Medical staffs should be taught about how to improve their con- sciousness of law and regulations and how to write medical records correctly and truthfully. They need to strictly control segments of medical document, to strengthen the management of on-the-run medical records for guarantee their quality, and to strengthen safety of medical records information in order to play their due role. The department of medical records should implement management systems of medical records for making sure smooth work pro- cedure and the completeness of medical records materials and timeliness of medical records utility and medical safety which can prevent medical tangle and maintain hospital for avoiding huge lost and risk.