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病历是记录医疗活动最重要的文书,又是医疗质量评定、医疗质量监督管理的重要依据,它既具有科学价值,同时又有法学意义。故此卫生部、国家中医药管理局颁发了《医疗机构病历管理规定》和《病历书写基本规范(试行)》。省也据此作出了具体细则性规定来规范病历书写。在执行过程中仍存有较大偏差,为什么会出现这种情况? 随着医疗逐步市场化,政府对医院的投入越来越少,现在,医疗市场竞争日趋白热化,级医院都在积极争取市场份额及经济效益的最大化。院上下都认同:要经济指标上去了,诊疗不出事故,人投诉是最重要的,其他都是次要的。使得
Medical records are the most important instruments for recording medical activities and an important basis for medical quality assessment and medical quality supervision and management. It not only has scientific value but also has legal significance. Therefore, the Ministry of Health and the State Administration of Traditional Chinese Medicine issued the “Regulations on the Management of Medical Records of Medical Institutions” and the “Basic Norms of Medical Records Writing (Trial)”. The province also made detailed rules to regulate the medical records accordingly. In the process of implementation, there are still large deviations. Why is this happening? With the gradual marketization of medical services, the government has less and less investment in hospitals. Nowadays, the competition in the medical market is becoming more and more intense. Hospitals are all actively seeking the market Share and maximize economic benefits. Hospital all agree: to economic indicators up, no accident diagnosis and treatment, complaints are the most important, others are secondary. Make