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随着各医院信息网络的建设和完善,类电子病历已普遍使用,给医务人员带来了前所未有的便捷。然而,由于方便,病历没有严格按照《病历书写基本规范(试行)》(下称规范)要求书写时情况常有发生。这种不规范书写病历给医院带来了不少麻烦,其中之一就是使医院医疗纠纷呈明显上升趋势。那么,不规范书写病历,究竟将会带来什么样的后果呢?
With the construction and improvement of hospital information networks, electronic medical records have been widely used, which has brought unprecedented convenience to medical personnel. However, due to convenience, medical records often do not occur when the medical records are not written in strict accordance with the requirements of the “Basic Rules for Writing Medical Records (Trial)” (hereinafter referred to as the “norms”). This irregular written medical record has brought a lot of trouble to the hospital, one of which is to make the hospital medical disputes show a clear upward trend. Then, what kind of consequences will result from non-standard written medical records?