复印病案的情况调查与分析

The Statistics and Analysis on the Copy of the Medical Records

目的调查病人复印病案的现状和目的,以进一步规范病案管理,提高病案质量。方法对本院3年来申请复印病案资料进行回顾性统计分析。结果复印病案办理大病统筹的数量占第一位,其次为报销凭证、司法鉴定和保险理赔等。结论落实《医疗机构病历管理规定》,加强病历复印管理工作,从而体现病案的社会价值,尊重患者的知情权,确保病案信息的完整性、准确性,维护医患双方的合法权益,使病案信最大限度的为社会服务。

Objective To investigate the status quo and purpose of the patients＇ copying the medical records, to standardize the management of the medical records, and increase the quality of the medical records. Methods The data of applying for copying the medical records was retrospectively analyzed in 3 years. Results The major purpose of copying the medical records was for health insurance covering major cases of illness, and others were expert evidence and compensation of medical insure. Condusion According to the Regulation on the Administration of the Medical Records, we make a good administration, fully exert the value of medical records, and respect the patient＇s right of learning the truth, keep the medical records in good integrity and accuracy, care the rights for both patients and medical institutions, and serve the social better.