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病历是医院管理和病种质量控制的重要信息资料。病历资料的统计学处理和分析,是医务人员进行医疗、科研、教学等工作的重要资料来源,也是评价医疗道德和医疗质量管理水平的第一手资料。有时还为政法工作提供真实可靠的素材,在处理医疗纠纷、伤残及某些医疗诉讼案时,病历是判明责任、做出正确裁定的重要依据。病历书写质量的优与劣,直接反映医院的医疗质量水平和管理水平。而近年来在某些医院病历书写质量被忽视,致使病历书写质量呈下降趋势,为了评价书
Medical records are important information materials for hospital management and disease quality control. Statistical analysis and analysis of medical records is an important source of information for medical personnel in the fields of medical treatment, scientific research, and teaching. It is also first-hand information on the evaluation of medical ethics and medical quality management. Sometimes it provides truthful and reliable materials for the political and legal work. When dealing with medical disputes, disability and certain medical lawsuits, medical records are an important basis for determining responsibility and making correct decisions. The merits and demerits of medical record writing quality directly reflect the hospital’s medical quality and management level. In recent years, the quality of medical records has been neglected in some hospitals, resulting in a downward trend in the writing quality of medical records.