病案是病情发展和医疗过程的真实记录,是医疗、教学、科研、医院和卫生行政管理、卫生统计、医疗保险理赔、疾病和伤残事故鉴定以及事故处理的重要法律依据。有关部门在依据病案记录处理事故时,会逐字逐句地推敲,任何一点疏忽差错甚至语言含混都可能对病人、对医师或对医院有某种不利的影响。写好病案记录,保证病案质量,是杜绝因病案记录存在缺陷引发医疗纠纷的关键。 The medical record is the true record of the development of the disease and the medical process. It is an important legal basis for medical treatment, teaching, research, hospital and health administration, health statistics, medical insurance claims, identification of diseases and disability accidents, and accident handling. When the relevant departments deal with accidents based on medical records, they will scrutinize them word-by-word. Any negligence or even linguistic confusion may have an adverse effect on the patient, the doctor or the hospital. Writing medical records and ensuring the quality of medical records is the key to preventing medical disputes caused by flaws in medical record records.