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以往我院病案都无目录页,病案外借归档时是否缺页或缺项不得而知,为此产生一些医疗纠纷,因此目录页的设置在病案管理中极为重要,这直接关系到病人的权益和医院的信誉。我院根据国家中医药管理局颁布的《中医病案规范》,加强病案管理于2000年10月对所有出院病人的病案设置目录页,即主管医师在病人出院后对其所有资料进行详细清点,附在病案上,这项工作的开展不仅使我院的病案管理上了一个台阶,而且为病案管理走上法
In the past, there were no catalog pages in the medical records of our hospital. It was unknown whether the missing pages or items were missing when the medical records were borrowed and archived. As a result, some medical disputes occurred. Therefore, the setting of the catalog page is extremely important in the management of medical records. This is directly related to the rights of patients. And the credibility of the hospital. In accordance with the TCM Medical Record Regulations promulgated by the State Administration of Traditional Chinese Medicine, our hospital strengthens medical record management in October 2000 for all patients discharged from the hospital’s medical record set up directory page, that is, the competent physician will record detailed information on all patients after discharge from the hospital. In terms of medical records, the development of this work has not only brought the medical record management of our hospital to a higher level, but has also taken the path to medical record management.