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医院病历档案是医疗活动的原始记录,是医疗、教学、科研的第一手重要资料,是医院医疗质量及质量控制、检查和考核的依据,也是提高医学发展水平和疾病诊治质量的基础,更是处理医疗纠纷举证倒置的有效证据。所以病历档案管理目前已成为医院管理工作中不可忽视的重要组成部分。本文将就当前病历管理中存在的不足及其对策作简要探讨。
The hospital medical history file is the original record of medical activities and is the first-hand material for medical treatment, teaching, and scientific research. It is the basis for hospital medical quality and quality control, inspection and assessment, and also the basis for improving medical development and the quality of disease diagnosis and treatment. It is effective evidence to handle the inversion of evidence in medical disputes. Therefore, medical record management has become an important part of hospital management. This article will briefly discuss the current deficiencies in the management of medical records and their countermeasures.