区分主客观病历管理的弊端分析及修改建议

Deficiency Analysis and Modification Proposals for Management of Subjective and Objective Medical Record

目前我国将病历划分为主观和客观部分进行管理,限制患者查阅和复制主观病历资料。针对我国现行的病历管理区分为主客观病历的现状,对区分主客观病历在临床操作中的困境、存在的弊端进行分析。通过探讨病历的本质、用途,从有利于保护病人知情权和推动医学进步的角度,对病历管理规定提出了修改建议。

Aiming at the clinical practice predicament caused by current medical record management in China, the deficiency of classified management of subjective and objective medical record is analyzed. According to the research data from health management institute, the article discussed the function of medical record, and proposes the modification suggestions, based on the principle of protecting patients＇ knowing right to propose the rectified suggestions for record management regulation.