病案是推定医疗过错及医疗事故判断的重要法律依据,因此病案质量十分重要,病历质量管理应依法书写、依法管理。病历书写必须客观、真实、准确完整;恪守病历书写的资格与权限,符合医疗行政部门的有关规定要求;并在规定的时间内完成;病历书写的内容也必须符合法律法规的规定;重视患者的知情权和知情同意书的签署。 Medical records are presumed medical malpractice and medical malpractice to judge the important legal basis, the quality of medical records is very important, medical record quality management should be written according to law, according to the law. Medical record writing must be objective, true, accurate and complete; abide by the medical record writing qualifications and authority, in line with the relevant provisions of the medical administrative department requirements; and completed within the prescribed time; medical records must also comply with the provisions of laws and regulations; attention to patients The right to know and the signing of informed consent.