依法依规抓好病历书写质量

Improving the Medical Record Quality by Observing the Relevant Laws and Regulations

病历是推定医疗过错及医疗事故判断的重要书证,病历质量十分重要,病历质量管理应树立依法书写、依法管理的观念。病历书写必须客观、真实、准确;病历的书写者必须符合医疗行政部门的有关规定;病历的书写必须在规定的时间内完成;病历书写的内容必须符合法律法规的规定;重视患者的知情权和知情同意书的签署。

Case history is an important documented evidence for medical mistake and medical accident. The quality of case history is very im- provement. In the management of case history quality, the writing and management of case history should be done according to the law. The writing of case history should be objective, real and true; the writer should be accorded with the ordain of medical service; the writing should be finished at specified time; the comtent should be accorded with the ordain of the law and regulation; hte informed comsent right of patients and subscribe of informed consent form should be regarded.