病案管理中的医学伦理问题

Medical Ethics Problems of Medical Record Management

病案管理中的医学伦理问题越来越受到人们的关注,正在我国进行的医疗体制和社会保障机制的改革,医疗法制尚不健全,医患纠纷日益增多。在现代医院管理中,随着医院技术设备的现代化,病案作为医疗活动信息的主要载体,不仅是医疗、教学、科研的第一手资料,而且也是医疗质量、技术水平、管理水平综合评价的依据。如何高效、准确、及时管理病案、及时反馈病人所有信息、及时了解医护人员对病人护理的历史记录,是医疗信息化建设的奋斗目标,因此,医院必须相应培养一支具有良好素质的病案管理队伍,以进一步加强病案管理工作,确保医院的宏观调控和科学管理的实施。

Medical ethics of Medical record management problems are more and more concerned. In this paper, the medical record management and medical ethical problems were expounded. And some corresponding solving methods are puts forward. The reform of the health care system and so- cial security mechanisms is underway in our country. Medical legal system is not perfect. Doctor - patient dispute increased day by day. Medical records, the main carrier of medical treatment activity information, are not only first hand information of medical treatment, teaching and scientific re- search, but also the comprehensive evaluation basis of medical treatment quality, technical level, management level. How to manage medical record efficiently, accurately and timely, couple back patient information timely, understand the history nursing records timely, are the medical information con- struction goals. Therefore, the hospital must cultivate a good medical record management team, further strengthen medical record management, ensure macro - control and scientific management.