基于门急诊病案管理缺陷的思考

文章分析了门（急）诊病案管理过程中存在着诸多安全隐患，如，病案管理制度不健全、病历记录不全、操作无记录等问题。有碍于患者安全和医疗质量的提高。另一方面容易引发医疗纠纷，不利于构建和谐的医疗环境。因此，规范病案管理、提高医务人员对病案重要性的认知和证据意识，对于防范医疗纠纷、特别是防范日益增多的涉及病历的纠纷有着现实意义，应当引起医院管理层的高度重视。

The Thought of Outpatient and Emergency Medical Records Management Defects

This paper analyzes many potential safety hazards of outpatient and emergency medical records management, such as medi- cal record management system is not sound, record is not complete, no operation record, etc. which is not conducive to patient safety and medical quality improving. On the other hand, they can cause the medical disputes, not conducive to the construction of a harmonious medi- cal environment. Therefore, hospital management should draw great attention to regulating medical records management, improving cognition of the importance of medical records and evidence awareness. It has a realistic significance to prevent medical disputes, especially against a growing number of disputes involving medical records.