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病历档案(以下简称病案)是医学科学和医院建设的宝贵资料,是临床诊治、教学和科研的重要依据。一、病案的作用(一)据统计,80%以上临床科研的基础数据来自病案,而不同时期的病案能反映当时的医学发展状况。由于病案记载了医护人员在临床工作中收集和占有的第一手资料,医疗、护理全过程的原始记录,具有法律效力,这是病案的唯一性。(二)病案为各级医务人员和科研工作者提供真实教材和可靠依据。病案由对患者诊断治疗过程中形成的病史资料转化而来。罕见病例和疑难病例能为医务人员提供科研资料和数据。(三)病案为医疗统计提供充分依据。医疗统计是医院分级管理的重要组成部分,它能反映医疗工作数量和质量,为医院管理提供重要信息。它真实地提供各科疾病发生发展、疗效等各种信息,并为流行性疾病提供防治措施。二、病案的科学管理病案的管理是一项专业性工作。病案的规范化、标准化管理在医院分级管理中
Medical record files (hereinafter referred to as medical records) are valuable information for medical science and hospital construction, and are an important basis for clinical diagnosis and treatment, teaching, and scientific research. First, the role of medical records (A) According to statistics, more than 80% of basic data for clinical research from the medical record, and different periods of medical records can reflect the medical development at the time. As the medical record records the first-hand information collected and occupied by the medical staff in clinical work, the original records of the whole process of medical treatment and nursing have legal validity, which is the uniqueness of the medical record. (b) Medical records provide true teaching materials and reliable evidence for all levels of medical personnel and scientific research workers. The medical record is transformed from the data of the medical history formed during the diagnosis and treatment of the patient. Rare and difficult cases can provide medical personnel with scientific research data and data. (3) Medical records provide sufficient basis for medical statistics. Medical statistics are an important part of the hospital’s hierarchical management. It can reflect the quantity and quality of medical work and provide important information for hospital management. It truly provides information on the development, efficacy, etc. of various diseases, and provides prevention and treatment measures for epidemic diseases. Second, the scientific management of medical records The management of medical records is a professional work. Standardized and standardized management of medical records in hospital management