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2002版的《医疗机构病历管理规定》出台使我国病案管理真正走上了有法可依,有法必依的道路,在此基础上修订的2013版的推出进一步明确电子病历与纸质病历具有同等效力,新增了针对未完成病历的封存和封存后的病历原件的相应规范,首次提出的当医疗机构发生名称变更或撤销时该机构的病案保存相关规定等新增和修改条款。通过研读比较新旧两版的《医疗机构病历管理规定》,对新增8条款、重大改动20条款、修改较小或未修改4条款分别进行研究学习,可以尽快掌握新规的精神并用于医疗管理、病历管理工作中。
2002 version of “medical institutions, medical records management regulations,” the introduction of China’s medical records management really embarked on a law, according to the law, on the basis of the revised version of 2013 to further clarify the electronic medical records and paper medical records have Equivalence, the new unopened medical records for the sealed and sealed medical records corresponding to the original norms, the first proposed changes in the name of the medical institutions or withdrawal of the institution’s record-keeping requirements and other new and amended provisions. By studying and comparing the Regulations on the Management of Medical Records of Medical Institutions between the new and the old versions, the study and study on the addition of 8 articles, major changes of 20 articles and minor or unmodified articles, respectively, can grasp the spirit of the new regulations and be used for medical management , Medical records management.