关键词: 封存病历, 医疗纠纷, 病案管理

Abstract: Objective To analyze the errors in the sealed medical records，and to explore the reasonable and legal management measures for the medical records. Methods 62 sealed medical records from September 2006 to September 2016 were statistically analyzed and classified for the year of occurrence，involving departments and so on，combined with the results of medical disputes to analyze the qualities and problems in medical records. Results Disputes records with negotiated settlement were 30 cases，accounted for 48. 4%；disputes records with judicial and medical identification judgment were 15 cases，accounted for 24. 2%；disputes records with medical mistakes were 38 cases，accounted for 61. 3%；records with hospital full responsibility were 8 cases，accounted for 12. 9% ，the majority of these medical records were in depatments of orthopedics，obstetrics and gynecology，general surgery. Conclusion Medical staffs need to strengthen the ability of medical record writing and communication between doctors and patients，in order to reduce or avoid the occurrence of medical disputes.

Key words: sealed records, medical disputes, management of medical records