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目的 探讨新形势下病历书写与医疗纠纷的关系。方法 对照新《医疗事故处理条例》,分析目前住院病历中常见的书写缺陷及对策。结果 住院志、病程记录、各种辅助报告单存在亟待重视、解决的书写缺陷;各种知情同意书尚需建立健全。结论 主观重视、客观负责、严格质控每一份病历的书写,完善知情同意书的设计和签署,防范医疗纠纷的发生。
Objective To explore the relationship between medical records and medical disputes in the new situation. Methods According to the new “Medical Accident Treatment Regulations”, the common writing defects and countermeasures in current inpatient medical records were analyzed. Results The hospitalization records, the course records, and various supplementary report forms need to pay attention to and solve the writing defects; all kinds of informed consent forms still need to be established. Conclusion Subjective attention, objective and responsible, strict quality control of each medical record, improvement of the design and signing of informed consent, and prevention of medical disputes.