论文部分内容阅读
现行的相关法律法规对指导病案封存和开封方法没有详细指引,实际应用中常有漏洞容易引发额外医疗纠纷。目前我们的病案封存工作中仍然存在对封存申请人审核不严、封存申请手续不齐、封袋的书写不完整、封存好的病案由何部门保管等许多问题,需要医疗机构加强对住院病案封存的规范化及合法化管理。本文通过对照相关法律法规,探讨病案封存和开封的方法,保护医患双方的合法权益,并结合实际工作制定具体方案:(1)确定及审核封存和开封病案的合法申请人;(2)病案封存的内容及可以复印的内容;(3)封袋的书写内容;(4)封存病案的管理;(5)封存病案的启封时间和方法。
The relevant laws and regulations in place do not provide any detailed guidelines on how to instruct medical records storage and opening. There are often loopholes in practical applications that will easily lead to additional medical disputes. At present, there are still many problems in the work of medical record storage, such as the lax auditing of the applicants, the incomplete application procedures, the incomplete writing of the sealed bags, the custody of the well-kept medical records by the departments, and the need for the medical institutions to strengthen the storage of inpatient medical records The standardization and legal management. This article examines the method of medical record sequestration and Kaifeng according to relevant laws and regulations, protects the legitimate rights and interests of both doctors and patients, and formulates the concrete plan according to the actual work: (1) Confirm and examine the legal applicant who sequestered and Kaifeng medical record; (2) (3) envelope writing content; (4) storage of medical records management; (5) sealed medical records of the opening time and method.