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目的提高病案管理水平,病案书写质量。方法对我院2005年1月～12月病案资料复印情况进行分析结果病历资料复印申请人员以保险公司最多,其次患者本人及家属或委托人；复印目的以商业保险理赔,社保医疗、司法鉴定、伤残鉴定和复诊、转院所占比例大；复印张数以各种医学影像报告单,病理检验报告单,生化检验单为最多。结论做好病历复印T作,需要全院各科室、各部门协同努力,提高医疗质量、病案质量、病案管理工作质量,最大限度地满足社会的不同需求。
Objective To improve the medical record management, medical record writing quality. Methods The data of medical records in our hospital from January to December in 2005 were analyzed. The results showed that the number of applicants for medical records was the largest among insurance companies, followed by the patients and their relatives or clients; the purpose of copying was commercial insurance claims, social insurance, forensic appraisals, Disability identification and referral, the transfer of a large proportion of the number of copies to a variety of medical imaging reports, pathology test reports, biochemical test alone as the most. Conclusion To make a good copy of the medical record, all departments and departments of the hospital need to work together to improve the quality of medical care, the quality of medical records and the quality of medical records management, so as to meet the different needs of the society to the maximum.