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病案是医护人员在医疗活动中形成的应归档保存的医疗信息载体。病案不仅是医、教、研的重要参考资料,也是评价医疗质量、衡量医务人员业务水平的重要依据和标志。病案中记录的原始信息成为保险公司核保兑赔、交通肇事及伤残鉴定、医疗纠纷处理、计划生育、公检法办案的原始证明。随着医疗体制的改革及医疗保险的实施,院外单位、人员到医院借阅病案的数量日渐增多,随之而来的问题增多了。
A medical record is a medical information carrier that should be archived and kept by health care workers during medical activities. Medical records are not only an important reference for medicine, teaching and research, but also an important basis and symbol for evaluating the quality of medical care and measuring the professional standards of medical personnel. The original information recorded in the medical record has become the original proof of insurance claims, accident and traffic accident and disability identification, medical dispute resolution, family planning and public security law. With the reform of the medical system and the implementation of medical insurance, the number of hospital borrowed medical records from hospitals and personnel to the hospital has been on the rise and the consequent problems have increased.