【摘要】 病案是医院工作人员进行医疗服务、科研和教学的基础资料，也是患者进行医疗报销的凭证，如果发生医疗纠纷，也是司法部门处理案件的重要证据。由此可见，病例规范化管理工作有着十分重要的作用。因此，各个医院必须基于自己的实际情况，制定完善的、有条理、有重点的病案管理体制，落实责任主体制度，规范操作要求，提高病案管理工作的效率和质量，推动医院病案管理工作的现代化、科学化、规范化发展。本文对我国病案管理工作展开研究，分析其中存在的质量问题，结合我国病案管理工作的实际状况提出相关建议，从而提高质量控制手段的应用效果，为我国病案管理工作提供保障。更多还原

【Abstract】 Medical records are the basic information of medical services, scientifi c research and teaching for hospital staff, and the voucher of medical reimbursement for patients. If there is a medical dispute, it is also the important evidence for judicial departments to deal with cases. Thus, the standardized management of medical records plays a very important role. Therefore, each hospital must, based on its own actual situation, formulate a perfect, adjusted and focused medical record management system, implement the responsibility subject system, standardize the operation requirements, improve the efficiency and quality of medical record management, and promote the modernized, scientific and standardized development of hospital medical record management. This paper studies the medical record management in China,analyzes the existing quality problems, and puts forward relevant suggestions based on the actual situation of the medical record management in China, so as to improve the application effect of quality control means and provide guarantee for the medical record management in China.更多还原