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国家卫生和计划生育委员会颁布并负责解释的新版《医疗机构病历管理规定》已经于2014年1月1日起生效并实施。本次规章修订紧密结合病案管理工作的新发展趋势,完善了法规框架,充实了规章内容,提升了规章的可操作性与实用性。有很多亮点,肯定了电子病历的法律地位、封存环节病历与病案的复印件的操作、要求医疗机构定期对病案质量进行检查、评估、反馈等等,均为医疗机构的病案管理工作做出了具体可行的指导。其中第三章对门急诊、临床诊疗工作中容易产生纠纷的病历保管问题做出了专门规定,帮助医疗机构改进工作制度,缓解因此而导致的医患矛盾,防范医疗纠纷,具有十分重要的指导意义。
The new Medical Records Management Regulations, promulgated and explained by the National Health and Family Planning Commission, took effect and implemented on January 1, 2014. The revision of this regulation closely integrates the new development trend of medical record management, improves the legal framework, enriches the contents of the regulations, and improves the operability and practicability of the regulations. There are many bright spots, affirmed the legal status of electronic medical records, archive medical records and medical records, medical institutions require medical records on a regular basis to check the quality of assessment, feedback, etc., are medical institutions to make medical records management Specific feasible guidance. The third chapter has made special regulations on the medical record keeping in the emergency department, clinical diagnosis and treatment work which is easy to have disputes, which helps the medical organization to improve the working system, alleviate the contradiction between doctors and patients and prevent medical disputes, which is of great guiding significance .