病案质量与病案的科学化管理分析

摘要

The medical records are the carrier of the important information such as the treatment effect,the use situation,the physical sign and so on. Writing the medical records in the course of the treatment of the patients is the most important protection of disease treatment. Therefore,in order to improve the use of medical records in the actual treatment process,it is necessary to carry out scientific management mode of medical records management,thus ensuring the quality of medical records. Due to the lack of medical records writing and ensuring the quality of medical records in most hospitals in China,the medical records can not play a real role in the actual treatment process. In this paper,the current part of the hospital medical record writing problems,and the scientific management of medical records were analyzed,the scientific management of medical records were introduced in detail.%病案是反应患者治疗效果、用药情况、身体体征等重要信息的载体。在对患者治疗的过程中书写病案，是疾病治疗最重要的保障。所以，为了提高病案在实际治疗过程中的使用效果，就必须通过科学化的管理模式对病案进行管理，从而保证病案质量。由于当前我国大部分医院缺乏病案书写与保证病案质量的意识，导致在实际治疗过程中病案无法发挥出真正的作用。本文通过阐述当前部分医院病案书写存在的问题，并对病案科学管理方法进行分析，将病案科学化管理方式进行详细介绍。