论文部分内容阅读
目的门诊病案的管理,是病案管理专业较为常见的棘手问题,自《医疗事故处理条例》颁布以来,有关门诊病案问题矛盾更为突出,经常有门诊病案丢失病人投诉医院,分析北京市海淀区居民满淑敏因门诊病案丢失法律诉讼,对门诊病案如何管理进行思考。方法应用一种全市统一门诊病案手册,或医用光卡,便于计算机管理,病人自己保存携带方便,减少病人投诉的意见,缓解院方与病人的紧张关系,提高病人满意度。结果用“谁主张,谁举证”的法律法规,有利于维护病人和医院的权益。结论加强门诊病案管理,防止由医院管理的病案丢失,能从根本上改变我们病案管理的被动局面。
Objective The management of outpatient medical records is a common and intractable problem in the medical record management profession. Since the issuance of the “Medical Accident Handling Ordinance”, the contradiction between outpatient medical record problems has become more prominent. Patients with missing outpatient medical records have often complained about the hospital and analyzed the residents of Haidian District, Beijing. Man Shumin lost legal proceedings for outpatient medical records and thought about how to manage outpatient medical records. Methods The application of a city-wide out-patient medical record manual or medical optical card facilitates computer management, saves the patient’s own convenience, reduces patient complaints, relieves hospital-patient tension, and improves patient satisfaction. As a result, the laws and regulations of “who advocated and who provided evidence” were conducive to safeguarding the rights of patients and hospitals. Conclusion Strengthening the management of outpatient medical records to prevent the loss of medical records managed by hospitals can fundamentally change the passive situation of our medical record management.