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病案对医院开展医疗活动、科研活动以及其他社会服务活动发挥着重要的作用,是医院不可替代的无形财务,具有高度的科学性和严谨性[1]。病案指的是医院在提供医疗服务的总过程中以患者细致的病历资料、医务人员开据治疗临床处方、药方使用详情单等为主要的诊疗资料和信息[2]。近年来,随着病案在医院的应用和服务项目逐渐增多,病案应用范围与数量也在逐年攀升。然而病案管理现存的问题对医院提高医疗服务质量产生影响,由于病案质量较差,普遍引起患者的不满,
The medical record plays an important role in hospital’s medical activities, scientific research activities and other social service activities. It is an irreplaceable intangible finance of the hospital and has a high degree of scientificness and rigor [1]. Medical record refers to the hospital in the provision of medical services in the process of patient detailed medical records, medical staff according to the treatment of clinical prescriptions, the use of prescription details as the main treatment information and information [2]. In recent years, with the increasing application of medical records in hospitals and service items, the scope and number of medical records are also increasing year by year. However, the existing problems of medical records management have an impact on the quality of medical services provided by hospitals. Due to the poor quality of medical records, which generally cause patient dissatisfaction,