【摘要】如何加强病案质量管理,不是一句空话,而要实实在在体现、落实到每日的实际工作中。工作上的繁忙不应成为病案书写漏洞百出的借口和理由,针对普遍存在的不重视、应付心理,要把病案书写提高到法律意识层面上来,避免侥幸心理,使之成为真正意义上的法律依据,证明自身清白的有力武器,实际工作中加强病案书写的规范培训,采取各种形式和手段提高医务人员的病案书写质量,杜绝因病案记录存在缺陷引发医疗纠纷,为纠纷的防范提供可靠法律依据是医疗机构众多工作中应切实加强的重要环节。

    【关键词】病案书写质量医疗纠纷缺陷纠纷防范管理

    中图分类号:R197.323文献标识码:A文章编号:1005-0515(2010)02-067-03

    【Abstract】 How to enhance the quality of medical record management, and is not an empty talk, but to really reflect the implementation of the daily practical work. Medical record should not be busy at work writing an error-ridden excuses and reasons for the widespread neglect to cope with psychological, medical record writing should raise legal awareness level up, to avoid the chances to become the true sense of the legal basis for the to prove their innocence a powerful weapon, the actual work of writing standards to enhance training of medical records and take various forms and means of enhancing the quality of the medical staff of the medical record written to eliminate defects caused illness case on record of medical disputes,To prevent disputes and provide a reliable legal basis for a number of medical institutions should strengthen the work of an important part. ......