病案是客观、完整、连续记录患者病情变化、诊疗经过、治疗效果及最终转归的医疗文书,其质量好坏直接反映医疗机构的医疗水平。同时,当发生医疗纠纷时,病案又是判定是否存在医疗缺陷的重要证据[1]。有资料[2]显示,在近年来经法院处理的医疗纠纷案件中,因病案质量而败诉的案件占30%。为此,我们对我院2012年1月-2013年12月657份死亡病案的质量情况进行了回顾性分析。现报告如下。1临床资料 Medical records are objective, complete and continuous records of patients with changes in condition, diagnosis and treatment, the treatment outcome and the final outcome of the medical instruments, the quality of medical institutions directly reflect the quality of medical institutions. At the same time, when medical disputes occur, the medical record is an important evidence to determine whether there is a medical defect [1]. Data [2] shows that in the medical disputes cases handled by the courts in recent years, 30% of the cases lost due to the quality of medical records. To this end, we conducted a retrospective analysis of the quality of 657 deaths in our hospital from January 2012 to December 2013. The report is as follows. 1 clinical data