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病案是医疗事故鉴定最重要的法律依据,也是维护医患双方合法权益必要凭证。《医疗事故处理条例》中明确规定:患者有权复印和复制病历有关内容。医疗机构有义务提供复印或复制服务并加盖证明印记。这充分说明了病历不仅是医疗、教学、科研的需要,也是医疗纠纷处理的重要原始法律依据。因此,新形势要求病案管理必须更新理念,从传统的管理上升到法制化管理,由规章制度管理转变为法律监督管理。自觉保护病案的原始性、真实性和可靠性,以维护医患双方的合法权益。笔者认为规范病案管理应从以下几个方面着手。
The medical record is the most important legal basis for the identification of medical accidents, and it is also the necessary evidence for safeguarding the legitimate rights and interests of both doctors and patients. The “Medical Accidents Disposal Regulations” clearly stipulates that patients have the right to copy and copy medical records. Medical institutions are obliged to provide copying or copying services and to stamp proofs. This fully demonstrates that medical records are not only the needs of medical treatment, teaching, and scientific research, but also an important original legal basis for the handling of medical disputes. Therefore, the new situation requires that the medical record management must renew the concept, from the traditional management to the legalized management, and from the rules and regulations management to the legal supervision and management. Consciously protect the originality, authenticity, and reliability of the medical record in order to safeguard the legitimate rights and interests of both doctors and patients. The author believes that the management of standardized medical records should proceed from the following aspects.