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病案除了为医疗、教学、科研服务外,也被社会其他领域广为利用,如:医保病人报销、医患纠纷、商业保险理赔、工伤评残、办理病退、公检法办案取证等。使病案的借阅量明显增加,为防止病案丢失,涂改等,病案的规范化、制度化管理显得越来越重要,病案借阅的管理也成为重中之重。必须规范严格的病案借阅制度,确保病案及时完整的归档。病案管理人员必须建立完善精细的病案借阅管理制度,规范病案借阅手续,杜绝病案借阅中的违规行为,保护患者的隐私,维护病案的真实性、权威性和严肃性,保证医疗工作的正常运行。
Apart from medical treatment, teaching and scientific research services, medical records are also widely used in other fields of society, such as reimbursement of medical insurance patients, medical disputes, commercial insurance claims, disability assessment of work-related injury, medical treatment for illness, and evidence collection by public security organs. In order to prevent the loss of medical records and alterations, the standardized and systematic management of medical records has become more and more important. The management of medical records loans has also become the most important issue. Must strictly regulate the medical record borrowing system to ensure timely and complete medical records archiving. Medical record administrators must establish and perfect the management system of medical record borrowing, standardize the procedure of borrowing medical records, eliminate the irregularities in case borrowing, protect the privacy of patients, safeguard the authenticity, authority and seriousness of medical records and ensure the normal operation of medical work.