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目的了解病案复印的需求,制定应对措施。方法分析4197例病案复印情况。结果复印病案的请求以患者本人为主,保险公司、其他代理人次之。复印的目的主要用于保险机构医疗费报销、输血费用报销、办理特殊门诊、法律取证和医疗纠纷等。结论医院应严格执行《病历书写基本规范》,做到病历书写及时、准确、完整、详实,不断提高病案内涵质量。病案管理人员应加强自身业务能力学习,努力提高法律意识,积极开发病案信息资源及利用好病案资源,提高病案的社会使用价值。
Objective To understand the needs of medical records and to formulate countermeasures. Methods 4197 cases of medical records were analyzed. The results of the request to copy the patient to patients themselves, insurance companies, followed by other agents. The purpose of copying is mainly used for reimbursement of medical expenses by insurance institutions, reimbursement of blood transfusion expenses, special clinics, legal evidence collection and medical disputes. Conclusion The hospital should strictly enforce the “basic norms of medical record writing” so as to make the writing of medical records timely, accurate, complete and detailed, and continuously improve the quality of medical records. Medical record administrators should strengthen their own business ability to learn, and strive to raise awareness of the law, and actively develop the medical record information resources and make good use of medical records resources to improve the social value of medical records.