病历封存管理问题及对策

Investigation on Management Problems and Countermeasures of Medical Record Sealing

随着患者住院期间发生的医疗纠纷不断增多,对医院封存病历的管理提出了更高的要求,运行病历本身具有正在临床使用的价值,各项资料有规定完成时限的特点,同时还涉及住院期长的患者多次封存的情况,出院后原件的回收等问题,因此运行病历比终末病案的封存管理更为复杂。某院在十多年的封存病历管理工作中,针对封存运行病历原件或复印件、病历资料缺项、封存病历原件的回收、编号与保管等方面问题,不断改进环节流程,优化细节管理,采取严谨且开放的复印、封存流程以说服患方封存病历复印件;加强医师法律法规学习与病案科质控前移保证封存前病历的完整性;临床科室送交封存病历原件,一对一交接回收;改良编号为更合理的数字组合编号;加固保护并水平存放封存病历等措施,为医疗纠纷案件提供真实完整的病历资料,客观公正地维护医患双方的合法权益,同时避免产生新纠纷,最大限度确保医疗安全。

As the patients during hospitalization to the rising number of medical disputes,the management of the hospital seal records put forward higher requirements,running records itself is the value of clinical use,has the characteristics of the stipulated time limit to complete all information,at the same time also involves hospitalization period long patient has sealed,after discharge of the original recovery and so on questions,so running medical record is more complex than terminal medical record storage management. A hospital in more than 10 years of seal medical records management work,to seal running the original or copy of medical records,medical records lacunary,seal,the original records,number and storage problems,improving link process,optimization of detail management,take the strict and open copy,storage process to convince the side seal medical record copy. To strengthen the study of doctors＇ laws and regulations and to ensure the integrity of medical records before medical records are sealed; The original medical records were sent and sealed by the clinical department,and recovered one by one; Improved numbering for more reasonable combination of Numbers; Measures such as strengthening protection and level for sequestration medical records,medical records for the completion of medical disputes to provide real,objective and fair to safeguard the legitimate rights and interests of both doctors,avoid to produce the new dispute.