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随着我国经济体制和医疗体制的改革,传统的就医模式正在改变,医院作为提供医疗服务的市场单位,正在从卖方市场向买方市场转变。而参加医疗保险的人员日益增多,因此,将有关医疗保险的医疗记录纳入病历质量检查中,不仅是医疗工作的需要,也是争取医院合法利益,提高医院两个效益的重要保障。医疗保险病人的病历检查主要围绕病案首页、住院志、病程记录、知情同意书、医嘱、体温单以及针对医疗保险规定,检查病历书写的准确性、完整性、合理性和连续性。
With the reform of China’s economic system and medical system, the traditional mode of medical treatment is changing. As a market unit providing medical services, the hospital is shifting from a seller’s market to a buyer’s market. The number of people participating in medical insurance is increasing. Therefore, incorporating the medical records of medical insurance into the medical records quality inspection is not only necessary for medical work, but also an important guarantee for securing the legitimate interests of the hospital and improving the two benefits of the hospital. The medical records of medical insurance patients mainly examine the accuracy, completeness, rationality and continuity of medical record writing based on the first page of medical records, inpatient records, course records, informed consent form, medical orders, body temperature lists and medical insurance regulations.