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病案作为记录患者在就医期间,尤其是在住院中的诊断、治疗、护理、康复、心理全过程的唯一一份记录,是患者从入院到出院全部诊疗过程的医疗和法律文献。随着《医疗事故处理条例》和《医疗机构病历管理规定》的实施,病案的内在价值和法律作用越来越受到医院、患者和社会各界的关注。在新形势下,如何做好病案管理工作,既最大限度地发挥病案所具有的实用价值,同时又有效防范因案管理不当引起的纠纷,是每一个病案管理工作者应当思考的课题。
The medical record is the only record that records the patient’s diagnosis, treatment, nursing, rehabilitation, and psychological whole process during hospitalization, especially in hospitalization. It is the medical and legal documentation of the patient’s entire process from hospital admission to discharge. With the implementation of Regulations for the Treatment of Medical Accidents and the Regulations for the Management of Case History of Medical Institutions, the intrinsic value and legal role of medical records are increasingly concerned by hospitals, patients, and all walks of life. Under the new circumstances, how to do a good job in the management of medical records to maximize the practical value of medical records and effectively prevent disputes caused by improper management of cases is a task that every medical record management worker should consider.