门(急)诊病案管理的主要缺陷由现行门(急)诊病案管理模式的弊病造成,在电子病案远不能普及、门(急)诊病案的管理模式还不可能发生根本性转变的背景下,门(急)诊病案要需努力做到病历书写要体现患者个人信息的完整性、体现病历记录内容的完整性、体现核心制度落实情况、体现医疗告知与门诊随诊等内容,更好地防范医疗纠纷。 The major shortcomings in the management of emergency medical records are caused by the shortcomings of the existing emergency medical records management model. Against the background of the fact that electronic medical records are far from universal and the management model of medical records (emergency) is not yet fundamentally changed (Emergency) medical records need to be hard to do medical record writing to reflect the integrity of the patient’s personal information, reflecting the integrity of the medical record content, reflecting the implementation of the core system, reflecting the medical advice and out-patient clinics and other content, better Prevent medical disputes.