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目的体现和尊重病员的知情权,做好病案质量管理和医院维权。方法通过开展病历资料复印工作的实践,加强对病历资料复印申请人的宣传和对医务人员的教育,配置专门人员、设备,完备受理病历资料复印程序,完善登记做好汇总、统计。结果申请病历复印的病人大多数是本地病员,以内科、外科、儿科住院病人为主,以病人和家属最多、保险机构之次,复印目的主要用于继续医疗、健康保健、保险机构调查、医疗费用报销。结论只有通过不断提高和改进病案质量,从病案档案信息资料中寻求提高医疗质量,降低服务成本的有效途径,确保病案资料的作用和价值,让病案信息最大限度的为社会各界服务,让社会各方面人士都从中受益。
Objective To reflect and respect the patient’s right to information, good medical record quality management and hospital rights. Methods Through the practice of photocopying medical records, we strengthened the publicity of medical records applicants and the education of medical staffs, equipped specialized personnel and equipment, fully accepted the photocopying procedures of medical record materials, and improved the registration to make a summary and statistics. Results The majority of patients applying for medical records were local patients. The main patients were medical, surgical and pediatric inpatients with the largest number of patients and their families. The second is for insurance agencies and the other for photocopying purposes. They were mainly used for continuing medical care, health care, insurance agency investigation and medical treatment Reimbursement. Conclusion Only by continuously improving and improving the quality of medical records, seeking effective ways to improve the medical quality and reduce the service costs from the medical records information, to ensure the role and value of the medical records information, to maximize the medical records information for all sectors of the community, People have benefited from it.