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病历是综合评价患者从入院到出院全过程的院方工作质量的一个重要手段和指标。是反映院方医疗技术水平、管理水平的重要依据。同时病历文件也是医疗机构的举证资料。并能为医疗事故和纠纷提供可靠的法律依据。提高病历质量将有效的提高医院的综合水平。但是由于医护人员法律意识淡薄、专业知识缺失、缺乏评估技巧等问题,导致病历质量难以落实。加强病历质量的监控是确实提高病历质量的重要手段。
Medical record is a comprehensive evaluation of patients from hospital to discharge the entire process of hospital quality of work is an important means and indicators. Is to reflect the hospital medical technology level, an important basis for the management level. Medical records at the same time the document is also evidence of medical institutions. And for medical malpractice and disputes provide a reliable legal basis. Improve the quality of medical records will effectively improve the overall level of the hospital. However, due to the weak legal awareness of medical staff, lack of expertise, lack of assessment skills and other issues, resulting in the quality of medical records is difficult to implement. To strengthen the monitoring of the quality of medical records is an important means to improve the quality of medical records.