《医疗机构病历管理规定》2013版研读

Study on the 2013 Edition of "Regulations on Medical Records Management in Medical Institutions"

2002版的《医疗机构病历管理规定》出台使我国病案管理真正走上了有法可依,有法必依的道路,在此基础上修订的2013版的推出进一步明确电子病历与纸质病历具有同等效力,新增了针对未完成病历的封存和封存后的病历原件的相应规范,首次提出的当医疗机构发生名称变更或撤销时该机构的病案保存相关规定等新增和修改条款。通过研读比较新旧两版的《医疗机构病历管理规定》,对新增8条款、重大改动20条款、修改较小或未修改4条款分别进行研究学习,可以尽快掌握新规的精神并用于医疗管理、病历管理工作中。

The announced of 2002 edition of the ＂Regulations of Medical Records Management in Medical h^stitutions＂ made the medical record management follow the law of the road in our nation. The announcement of 2013 edition revised on the basis of that further clarified the electronic medical records share the same effect with the paper records, newly added the keep up of unfinished medical records and relevant regulations of original medical records, and put forward newly increased and amending clauses on the keep up regulations of medical records when the names changes or withdraw of medical institutions for the first time. To conduct a study on the eight items newly added, twenty items significantly modified and four items with little or no change through the comparative research on the two editions of ＂Regulations on Medical Records Management in Medical Institutions＂, then we could acquire the spirit and apply into the management work of medical treatment and medical records as soon as possible.