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目的明确病案是有关病人健康情况的文件资料,是法定的医学文件。方法强调医务人员在病案形成过程中应负的法律责任。其中患者和家属具有依法提供可靠信息的义务。讨论当医患发生矛盾时,病案将作为评议、处理或判明责任的重要依据,可以保障医务人员和患者的合法权益不受侵犯。结论病案的收集、整理、保存都需要法律依据;病案的安全需要法律支持;病案的利用需要法律保证。
The purpose is to define the medical record as a document on the patient’s health and is a statutory medical document. The method emphasizes the legal responsibilities of medical personnel in the formation of medical records. Patients and their families have the obligation to provide reliable information according to law. Discussion When a doctor-patient conflict occurs, the medical record will serve as an important basis for appraising, handling, or clarifying the responsibility, and it will protect the legitimate rights of medical personnel and patients from infringement. Conclusion The collection, sorting and preservation of medical records require legal basis; the safety of medical records requires legal support; the use of medical records requires legal guarantees.