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病史档案是医院档案的重要组成部分,是医务人员在疾病诊断、治疗、护理过程中形成的,以各种文字、图表、声像等不同形式和载体,对病员的健康状况及罹患伤病的诊治所作的全面而连续的原始记录。也是发生医疗事故或纠纷后在论定是非、判明责任,以至医疗技术鉴定或司法取证赖以立论的根据。因此,病案特别是病案缺陷问题,常常成为医疗纠纷在司法裁判上的一个焦点问题。 一、现行病史档案利用所存在的问题 长期以来,全国各医院都按照国家卫生部规定的病案管理制度执行,医院只能对门诊病人给予病案,对住院病人,医生则根据实际情况及病人和家属的要求介绍病情,但病人和家属不得随意翻阅、复印病案,名日实行保护性医疗制度。在发生医疗纠纷时,病案要
The medical history file is an important part of the hospital’s archives. It is formed by medical personnel in the process of disease diagnosis, treatment, and nursing. It uses various forms and carriers such as various characters, diagrams, and audio and video to treat the patient’s health status and suffers injuries. A comprehensive and continuous original record of diagnosis and treatment. It is also the basis for determining the rights and wrongs of a medical malpractice or dispute, as well as the basis for medical technology appraisal or judicial evidence verification. Therefore, the medical record, especially the defect of medical records, has often become a focus issue for medical disputes in judicial decisions. I. Problems existing in the use of current medical history files For a long time, all hospitals in the country have been implemented in accordance with the medical record management system stipulated by the Ministry of Health. Hospitals can only provide medical records for outpatients. For inpatients, doctors are based on actual conditions and patients and their families. The requirements of the case were introduced, but the patients and their families were not allowed to read and copy medical records at random, and a protective medical system was implemented on a daily basis. When a medical dispute occurs, the case must be