病案管理中的医学伦理

Medical Ethics in the Management of Medical Records

病案管理是现代医疗质量管理的重要组成部分,医学伦理原则体现在病案管理的各个环节。病案管理要求各项病案管理操作满足符合患者利益、保护患者隐私权、尊重患者知情权及遵守法律等医学伦理要求。医学伦理贯穿于病案管理的始末,包括病案书写中的住院问诊、临床检查、诊疗计划、手术治疗、日常查房,病案归档中的纸质病案和电子病案的收集、整理、汇总和保存等,病案提供中的患者或第三方对病案资料的获取、临床或科研人员对病案资料的获取等方面。

Medical records management is an important part of modern medical quality management,and the principles of medical ethics have reflected in each aspect of medical records management.Medical ethics requirements such as satisfy the benefits of patients in the operations,protect the privacy rights of the patients,respect the informed rights and abide by the law are demanded in the management of medical records.Medical ethics runs through the beginning and end of medical records management,including hospitalized inquiry,clinical inspection,treatment plan,operation therapy,daily ward around,the collection,clear up,summary and storage of paper or electronic medical records in the archiving of medical records,as well as aspects of the acquirements of medical records materials from the patients,the third party and clinical or research staff.