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近几年,随着国家各项法律制度的不断完善,各行业相关法规的相断出台,人民群众的法律意识逐渐增强,维护自身的权益的愿望越来越强;又因医疗保障体制改革中,医疗费用支付方式的改变,使个人负担费用增加;人们在追求生活高质量的同时,对医疗服务也提出了更高的要求,多种因素引发的医疗纠纷呈明显上升趋势。在医疗纠纷的处理过程中,病案作为重要的证据而受到医患双方及社会各界的广泛关注。传统的沿袭了多年的病历书写
In recent years, with the constant improvement of various legal systems in various countries and the introduction of the relevant laws and regulations in various industries, the people’s legal awareness has been gradually strengthened and the desire to safeguard their rights and interests has become stronger and stronger. In the reform of the medical insurance system , The payment of medical expenses changes, so that individuals pay higher costs; people in the pursuit of high quality of life, but also put forward higher demands on medical services, medical disputes caused by many factors showed a clear upward trend. In the process of medical disputes, the medical records as an important evidence by both doctors and patients and the community attention. Traditionally followed many years of medical record writing