新形势下病案室如何与临床沟通

Medical records room how to communicate with clinical departments under the new situation

随着我国医疗体制改革的不断深入和社会走向现代化,前来病案室复印病案的患者越来越多,病案室医务人员的工作任务越来越繁琐,再加上2002年《医疗事故处理条例》的实施,病案的用途越来越广泛。由于每个人对病案复印的目的、用途不同,对病案的质量要求也有所不同。在当代社会,绝大多数患者前来复印病案是因为保险报销、伤残鉴定,而在保险报销及伤残鉴定的过程中,病案起主导作用。有时病案的问题影响患者保险报销不了或原本患者伤残已够评定标准而因病案问题导致伤残鉴定不够级,导致患者或患者家属有不良情绪,这时面对气急败坏的患者或患者家属,我们应积极与临床沟通,提高病案质量,避免医患纠纷,这是现代医院病案室的重中之重。病案室人员掌握沟通技巧化解医患矛盾,才能与病案复印患者及其家属建立一种互信关系,达到共赢目的。良好的与临床沟通,不仅提高了病案质量,也加强了院内各科室与病案室的联系。

With the deepening of China＇s medical reform and social modernization, there are more and more patients who come in medical records room to copying medical records, so the work tasks of medical staff in medical records room are more and more tedious, and plus the implementation of ＂Regulations on the handling of malpractice＂ since 2002, the use of medical records are more and more wide. Since each person＇s medical records copying purposes and use are different, the quality requirements for medical records is also different. In contemporary society, the most patients who come to copying medical records due to the insurance reimbursement and disability identification, and medical records play a leading role during the insurance reimbursement and disability identification. Sometimes the problems of medical records affecting the patient＇s insurance which can not be reimbursed or the patient＇s disability identification meeting the standard originally can not reach the standard due to the problems of medical records, which lead to the negative emotions of patients. When facing the angry patients or family members of patients, we should actively communicate with the clinical departments and improve the quality of medical records to avoid the medical disputes, which is the most important part in medical records room of modern hospital. Only medical staff in medical records room mastering communication skills to resolve the conflicts between doctors and patients, can establish a relationship of mutual trust with the patients or family members of patients who come in medical records room to copying medical records, and achieve win-win goal. Good communicating with clinical departments can improve the quality of medical records,and strengthen the association between the other department of hospital and medical records room.