新版《医疗机构病历管理规定》实施后病案保管问题的探讨

Discussion of Medical Records Safekeeping Problem after Implementation of New Edition of Medical Record Management Regulations of Medical Institutions

国家卫生和计划生育委员会颁布并负责解释的新版《医疗机构病历管理规定》已经于2014年1月1日起生效并实施。本次规章修订紧密结合病案管理工作的新发展趋势,完善了法规框架,充实了规章内容,提升了规章的可操作性与实用性。有很多亮点,肯定了电子病历的法律地位、封存环节病历与病案的复印件的操作、要求医疗机构定期对病案质量进行检查、评估、反馈等等,均为医疗机构的病案管理工作做出了具体可行的指导。其中第三章对门急诊、临床诊疗工作中容易产生纠纷的病历保管问题做出了专门规定,帮助医疗机构改进工作制度,缓解因此而导致的医患矛盾,防范医疗纠纷,具有十分重要的指导意义。

National health and family planning commission issued and shall be responsible for the interpretation of the new edition of medical record management regulations of medical institutions has come into effect and implemented on January 1, 2014. This regulations amendment is closely combined with the new development trend of medical record management, improve the regulatory framework, enrich the rules and content, and improve the operability and practical regulations. There are a lot of bright spots such as the affirmation of the legal status of electronic medical records, medical record copy in the link of seal up for safekeeping, ask for medical institutions to regularly check evaluate and feedback the quality of medical records, and so on. These measures have made the concrete guidance for medical record management of medical institutions. The third chapter made a special provision for the medical records safekeeping problems which prone to disputes in outpatient clinical diagnosis and treatment. It has important guiding significance in improving the medical institutions working system, alleviating the doctor-patient contradiction, and preventing medical disputes.