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病案作为医、教、研的主要载体,它的价值已得到医学界的认同。病案是患者伤残评定、医疗保险及医纠纷和医疗事故评定的法律依据。写好病案记录,保证病案的质量,是杜绝因病案记录存在缺陷引发医疗纠纷和医疗矛盾的关键,是医院管理的重要工作。
As the main carrier of medicine, teaching, and research, the medical record has its value recognized by the medical community. Medical records are the legal basis for disability assessment, medical insurance, medical disputes, and medical accident assessment. Writing medical records and ensuring the quality of medical records is the key to eliminating medical disputes and medical contradictions caused by defects in medical record records. It is an important task for hospital management.