病案借阅存在的问题与对策

The countermeasure to the problem exist in the medical record lending

目的:探讨怎样规范病案借阅管理,从而更加充分地体现病案的使用价值。方法:通过对病案借阅工作的总结,并结合我院实际情况进行分析。结果:在病案借阅管理中存在许多问题,如病案借阅手续不规范;医务人员及病案管理人员法律观念淡薄;病案使用范围不规范;特殊病案和科研病案没有严格管理;病案借阅时间没有严格限制;病案借阅管理系统不完善;病案借阅的奖惩制度没有执行。结论:通过健全和规范病案借阅制度,提高病案管理人员的专业水平和法律意识,提出有效的病案借阅管理措施,更加充分地体现病案的使用价值。

Objective：How to make regulations on medical record-lending development in order to increase the use-value of medical record. Methods： The medical record-lending work was sum up, and the results were analyzed combining with our hospital actual conditions. Results： There were many problems in the medical record-lending management： such as the procedures of medical record-lending didn＇t meet standard; the concept of law of health workers was weak; the apply range of medical record didn＇t match criterion; the special medical records and medical records for research weren＇t strictly regulated; the lending time range weren＇t strictly limited; the medical record-lending management system wasn＇t complete; the system of rewards and punishments wasn＇t carried out strictly. Conclusion： In order to increase the use-value of medical record, we should perfect and regulate the medical record-lending system, improve the professional ability and consciousness of law of medical record-lending workers, and propose effective medical record-lending regulation measures.