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病历反映医疗护理工作的全过程,是医疗、教学、科研工作的重要资料。随着我国社会的进步和医疗体制改革的不断深入,城镇医保、新农合和民政救助政策的普及和商业保险的发展,患者法律意识的增强,病历作为重要的医疗法律依据,被社会各界越来越广泛的重视。《医疗事故处理条例》(国务院令第351号)规定,医疗机构应患者的要求,为其复印或者复制病历资料,可以按照规定收取工本费,收费标准由省、自治区、直辖市人民政府价格主管部门会同同级卫生行政部门规定。近几年来我院病历收费工作经历了由兼职到专职、由自定到统一、由手工到计算机三次质的变化。
Medical records reflect the entire process of medical care, medical, teaching, scientific research important information. With the progress of our society and the continuous deepening of medical system reform, the popularization of urban medical insurance, NCMS and civil assistance policies and the development of commercial insurance have strengthened the legal awareness of patients. Medical records, as an important medical legal basis, have been used by all sectors of society The more extensive the attention. The Medical Malpractice Ordinance (Decree No.351 of the State Council) stipulates that the medical institution may, at the request of the patient, copy the medical records or copy the medical record materials according to the regulations, and the fee shall be charged by the price department of the people’s government of the province, autonomous region or municipality directly under the Central Government With the same level of health administrative departments. In recent years, our hospital medical record work has experienced from part-time to full-time, from self-determination to unity, by hand to the computer three qualitative changes.