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文章分析了门(急)诊病案管理过程中存在着诸多安全隐患,如,病案管理制度不健全、病历记录不全、操作无记录等问题。有碍于患者安全和医疗质量的提高。另一方面容易引发医疗纠纷,不利于构建和谐的医疗环境。因此,规范病案管理、提高医务人员对病案重要性的认知和证据意识,对于防范医疗纠纷、特别是防范日益增多的涉及病历的纠纷有着现实意义,应当引起医院管理层的高度重视。
The article analyzes many hidden dangers in the process of door (emergency) medical record management, for example, the medical record management system is not perfect, the record of medical record is incomplete, and the operation is not recorded. Hinder the improvement of patient safety and medical quality. On the other hand it is easy to cause medical disputes, which is not conducive to building a harmonious medical environment. Therefore, regulating the medical record management and raising awareness of medical staffs on the importance of the medical record and awareness of the evidence have practical significance in preventing medical disputes, especially the prevention of a growing number of disputes involving medical records, which should arouse great attention of hospital management.