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《医疗机构病历管理规定》存在一些未详细说明的问题,如什么是有效身份证明,什么年份的病案可以复印等?这不仅影响医院为患者提供病历复印工作,更影响和谐医患关系,造成医患关系紧张;因此,一方面要完善《医疗机构病历管理规定》,另一方面,医院应利用出院记录等医疗文件进行详尽的告知义务,同时,应将住院检验、影像报告单一式两份,一份贴于病案中,一份直接给病人,这样能极大的方便患者,改善医患关系。
There are some issues that are not described in detail in the Regulations for Medical Records Management, such as what is a valid identity certificate and what year’s medical record can be copied. This not only affects the hospital’s provision of medical record copying for patients, but also affects the harmonious relationship between doctors and patients and causes medical problems. Tensions are strained; therefore, on the one hand, it is necessary to improve the “Regulations on Medical Records Management of Medical Institutions.” On the other hand, hospitals should use hospital discharge records and other medical documents to conduct detailed notification duties. At the same time, hospitalization and imaging reports should be duplicated. One is attached to the medical record and one is given directly to the patient. This can greatly facilitate the patient and improve the doctor-patient relationship.