摘要
病历书写应当符合客观、准确、及时、完整、规范的基本原则。不符合病历书写基本原则的病历,不能作为诊疗依据和作为教学、科研资料,也不能成为诉讼证据。本文针对当前医务人员书写病历存在的记载内容不真实、不准确、不完整、不规范、不及时等情形,提出加强医疗机构的病历制度建设、重视医疗机构病历监管工作、加强对医务人员病历法律意识的教育等对策。
Medical records should be consistent with the objective,accurate,timely,complete,and the basic principles of specification.Does not comply with the basic principles of medical records medical records,not as a basis for diagnosis and treatment,teaching and research data,Even it cannot become evidence in judicial proceedings. Content writing medical records exist current medical staff is untrue,inaccurate,incomplete,not standardized,untimely situation,countermeasures. Authors propose to strengthen the medical system construction of medical institutions,medical institutions,medical attention supervision,strengthen the medical staff records education and other countermeasures legal consciousness.
出处
《医学与社会》
2015年第1期19-22,共4页
Medicine and Society
基金
"十二五"国家科技支撑计划项目
编号为2012BAK16B02-2
关键词
病案
信息科学
诉讼
证据
Medical Record
Information Science
Litigation
Evidence
