谈病历真实性管理

Management of the Facticity of Medical Record

本文分析病历失真的原因,提出增加医疗信息的透明度、患者参与病历真实性监督、完善病历质量评定制度、加强对上级医师的监督、改善临床医师工作环境、加强病历管理的制度建设等措施。

The article analyzed the causes of medical records being unreal. It also put forward some corre- sponding measures, which included increasing diaphaneity of medical Information, taking sufferers to join in the su- pervision of medical record facticity, perfecting the system of assessing medical record quality, strengthening super- vision to higher - up doctor, improving the working conditions of clinic doctors, reinforcing the system construction of medical record management