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病案是医务人员执行医疗行为的全面记录和总结,是证明自己医疗行为正确、合法的依据,也是注意义务履行已否的载体。注意义务是法律赋予医务人员的一种法定义务,医务人员在整个诊疗过程中,重视完善履行其注意义务的同时,还要注重病案质量,以保护医患双方的合法权益,降低医疗风险,减少医疗纠纷,提高医疗质量。
A medical record is a comprehensive record and summary of the medical personnel’s performance of medical treatment. It is a basis for proving that the medical act is correct and legal and is also a matter of paying attention to the fulfillment of the obligation. The duty of care is a statutory obligation given to the medical staff by the law. While paying attention to perfecting the duty of care, the medical staff should pay attention to the quality of the medical record in order to protect the legitimate rights and interests of both doctors and patients, reduce the medical risk and reduce Medical disputes, improve medical quality.