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为防范因护理病历质量引起的医患纠纷,针对电子病案应用中出现的护理记录内容缺乏真实性、粘贴、复制他人记录、张冠李戴、记录不及时、用户名口令泄密等潜在法律问题,提出加强病历书写及相关知识培训,学习法律法规规范护理病历书写、严格实行电子病案系统安全管理和监督、抓好护理病历形成过程中的各个环节管理等管理措施,提高电子护理病案质量,避免因护理病案引起的法律纠纷。
In order to prevent the disputes between doctors and patients due to the quality of nursing medical record, aiming at the potential legal problems such as the lack of authenticity of nursing records in e-medical records application, the pasting and copying of others’ records, the failure to record in time, Writing and related knowledge training, learning laws and regulations to standardize nursing records writing, strictly implementing the electronic medical record system safety management and supervision, and taking good care of the various aspects of the management of nursing records in the process of management and other management measures to improve the quality of electronic nursing record to avoid cases caused by care Legal dispute.