病案是医务人员在医疗活动中直接形成的,记载患者从入院到出院的病情变化和诊疗情况,随着人们法律意识的增强和《医疗事故处理条例》的出台,病案的法律价值和佐证价值日显重要,病案管理工作也引起医院高度重视,本文就病案管理中发现的一些常见问题进行阐述与分析,并提出一些预防措施,以防范医疗纠纷的发生。 Medical records are medical personnel directly formed in the medical activities, record changes in the patient’s condition from admission to discharge and diagnosis and treatment, with the legal awareness of people and the “Medical Malpractice Ordinance” promulgated, the legal value of the medical record and supporting value date Significantly, the management of medical record also aroused the great attention of the hospital. This article elaborates and analyzes some common problems found in medical record management and puts forward some preventive measures to prevent the occurrence of medical disputes.