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目的了解我院病案资料复印基本情况,为规范管理提供科学依据。方法采用回顾性调查方法,对我院近三年病案资料复印数据进行统计分析。结果病案资料复印数逐年增加,并已成为商业保险理赔(住院险和学生险)、伤残鉴定、工伤鉴定、医保报帐、解决医疗事故和纠纷必不可少的重要依据。结论配备病案资料复印基本设施,依法加强病案资料复印管理极其重要。
Objective To understand the basic situation of copying medical records in our hospital and provide scientific basis for standard management. Methods A retrospective survey method was used to statistically analyze the copy data of medical records in the past three years in our hospital. As a result, the copy number of medical records has been increasing year by year, and it has become an indispensable important basis for commercial insurance claims (hospital insurance and student insurance), disability appraisal, work injury appraisal, medical insurance reimbursement, and resolution of medical accidents and disputes. Conclusion It is extremely important to provide basic facilities for the copying of medical records and to strengthen the management of copying medical records according to law.