我院是一所三级甲等具有1300张床位的综合性教学医院。当前,借阅病案的人员越来越多,不规范的借阅行为也随之增多,现就此问题展开剖析,并提出有效对策,以使病案借阅管理工作更规范化、具体化。 一、院外人员借阅病案存在问题 随着医疗体制的改革及社会基本医疗保险的实施,病案中记录的原始信息,如患者的既往史、现病史、主要临床诊断及用药治疗、检查等情况的记载都将成为保险公司核保、拒赔,公、检、法判明法律,伤残鉴定、事故、肇事、纠纷及计划生育方面的原始证明和依据。为此,院外人员借阅病案次数繁 Our college is a comprehensive teaching hospital with 1,300 beds. At present, more and more people are borrowing medical records, and irregular borrowing behaviors have also increased. Now we analyze this issue and propose effective countermeasures to make the management of medical record borrowing more standardized and specific. I. Problems with borrowing medical records by out-patients With the reform of the medical system and the implementation of social basic medical insurance, the original information recorded in medical records, such as the patient’s past history, current medical history, major clinical diagnosis, medication treatment, and inspections, were recorded. All of them will become the original proofs and basis for the insurance company’s underwriting, refusal to pay compensation, public, prosecution, and law-clarifying laws, disability appraisal, accidents, accidents, disputes, and family planning. For this reason, the number of medical records borrowed by the staff outside the hospital