《医疗机构病历管理规定》和《医疗事故处理条例》的颁布实施,新病案首页、新软件、ICD-10疾病分类编码的使用,使病案管理更加科学化,但我们在两年多的实践过程中,发现了一些问题,针对这些问题采取了切实可行的措施使病案质量逐步提高。 The promulgation and implementation of the “Medical Organization Medical Record Management Regulations” and “Medical Accident Handling Regulations”, the use of the new disease case homepage, new software, and ICD-10 disease classification codes have made the case management more scientific, but we have practiced over two years. In the past, some problems were discovered and practical measures were taken to address these issues so that the quality of medical records could be gradually improved.