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病历档案作为医院与患者双方唯一可以取证的原始资料,医院与患者双方一旦发生医疗纠纷,患者往往要求封存或复印病历档案,这就对病历档案的“及时性”提出了极高的要求。我院历来对病历档案的管理极为重视,严格按照“病历档案书写基本规范”的有关要求执行,即入院记录必须在24小
The medical record file is the only original data that can be collected by the hospital and the patient. Once a medical dispute occurs between the hospital and the patient, the patient often requires the medical records to be sealed or copied. This places high demands on the “timeliness” of medical records. Our hospital has always attached great importance to the management of medical record files and strictly complied with the relevant requirements of the “basic specification for medical record writing”. That is, admission records must be 24 hours old.