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病案是医疗卫生机构中最直接、最生动的健康信息文件,是对医院医疗质量、技术水平和管理水平进行综合评价的重要依据。它作为医疗、教学、科研、法律和预防保健等方面的信息载体,在医疗机构中越来越趋于重要的位置。近年来,随着医药卫生制度的改革,病案管理已经成为医院管理的重要组成部分,特别是医疗事故处理条例实施以来,如何加强病案管理、提高病案质量已经成为摆在各大医院面前的重要课题。
The medical record is the most direct and vivid health information document in the medical and health institutions, and is an important basis for the comprehensive evaluation of the hospital’s medical quality, technical level and management level. As an information carrier for medical treatment, teaching, scientific research, law, and preventive health care, it has become increasingly important in medical institutions. In recent years, with the reform of the medical and health system, medical record management has become an important part of hospital management. Especially since the implementation of medical accident handling regulations, how to strengthen the management of medical records and improve the quality of medical records has become an important issue facing major hospitals. .