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一份好的病案,能体现出医务人员为病人服务的专业素质、道德素质和文化素质。先有病案的形成,才能提到管理问题。所以,医生在病案管理工作中是第一位的。首先,医师要收集病人的原始资料,做系统、完整地描述,并把对病人的观察、诊断、治疗及护理情况准确地记录。 1999年5月1日开始执行的《中华人民共和国执行医师法》简科《医师法》第三章第二十三条明确指出:医师“必须亲自诊察、调查,并按照规定及时填
A good medical record can reflect the professional quality, moral quality, and cultural quality of medical personnel serving patients. Before the formation of a medical record can we mention management issues. Therefore, doctors are the first in the management of medical records. First, the physician collects the patient’s original data, makes a systematic and complete description, and accurately records the observation, diagnosis, treatment, and care of the patient. Article 23 of Chapter 3 of the “Physicians’ Law” of the “Medical Person’s Law of the People’s Republic of China” implemented on May 1, 1999 clearly stated that: "Doctors must be examined and investigated in person and filled out in accordance with regulations.