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病案是医护人员在医疗活动中对疾病诊断、治疗及转归全过程的客观记录,是确定患者健康状况的客观依据,是处理和解决医疗纠纷用的判定责任的法律依据。故病案存在的缺陷是引起医疗纠纷的安全隐患,为了维护医患双方的合法权益,医护人员要客观、认真、及时、完整地规范书写病历,以提高病案质量,减少或杜绝医疗纠纷的发生。
Medical record is the objective record of the whole process of diagnosis, treatment and outcome of medical treatment in medical activities. It is the objective basis for determining the patient’s health status and is the legal basis for determining and handling medical disputes. Therefore, the flaws in the medical records are caused by the hidden dangers of medical disputes. In order to safeguard the legitimate rights and interests of both doctors and patients, the medical staff should write medical records in an objective, serious, timely, and complete manner in order to improve the quality of medical records and reduce or eliminate the occurrence of medical disputes.