【摘要】 病历是推定医疗过错及医疗事故判断的重要书证,病历质量十分重要,病历质量管理应树立依法书写、依法管理的观念。病历书写必须客观、真实、准确;病历的书写者必须符合医疗行政部门的有关规定;病历的书写必须在规定的时间内完成;病历书写的内容必须符合法律法规的规定;重视患者的知情权和知情同意书的签署。更多还原

【Abstract】 Case history is an important documented evidence for medical mistake and medical accident. The quality of case history is very im-provement. In the management of case history quality, the writing and management of case history should be done according to the law. The writing of casehistory should be objective, real and true; the writer should be accorded with the ordain of medical service; the writing should be finished at specifiedtime; the comtent should be accorded with the ordain of the law and regulation; hte informed comsent right of patients and subscribe of informed consentform should be regarded.更多还原