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作为客观记录病人疾病诊疗全过程的文件,病历不仅是医院进行科学诊断的基础资料、科研教学资料,而且还是一种必要的法律证据。符合规范的正规病历可以避免医院举证时的被动局面,维护自身的合法权益。本期张新博博士的一组文章从病历的采集、撰写、归档、借阅等一系列过程入手,详细剖析医院病历管理中的常见疏忽、法律陷阱和法律责任问题,并提出自己的一套病历管理的风险预警和防范机制。
As a document that objectively records the whole course of patient’s disease diagnosis and treatment, medical records are not only the basic data, scientific research and teaching materials for the hospital for scientific diagnosis, but also a necessary legal evidence. A regular medical record that meets the regulations can avoid the passive situation in the hospital when it is used for proof, and safeguard its own legitimate rights and interests. In this issue, Dr. Zhang Xinbo’s set of articles begins with a series of processes including the collection, writing, archiving, and lending of medical records, and analyzes in detail the common negligence, legal traps, and legal liability problems in hospital medical record management, and proposes a set of medical record management. Risk early warning and prevention mechanisms.