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目的调查了解病案复印情况,并对其进行科学的分析,可以促使医院重视病案书写质量,加强对病案的管理。方法2336例病案复印的用途、各科所占比率进行分析。结果复印的用途以保险理赔为主占第一位,其次因出生医学证明遗失补办,后续治疗、大病统筹报销凭证、司法鉴定和和医疗纠纷等;复印的科别以产科、儿科为主。结论落实《医疗机构病历管理规定》。加强病历复印管理工作,从而体现病案的社会价值,尊重患者的知情权,确保病案信息的完整性、准确性,维护医患双方的合法权益,使病案信息最大限度的为社会服务。
Objective To investigate and understand the situation of photocopies and scientifically analyze them, which can prompt the hospital to pay attention to the quality of medical records and strengthen the management of medical records. Methods The use of 2336 cases of photocopies and the proportion of subjects were analyzed. The results of the use of copying insurance claims mainly took first place, followed by the birth of medical certificate lost re-supply, follow-up treatment, major disease reimbursement reimbursement certificate, judicial identification and medical disputes, etc.; copy of the department to obstetrics, pediatrics based. Conclusion The implementation of the “Regulations on Medical Records Management in Medical Institutions”. Strengthen the management of medical record copying so as to reflect the social value of the medical record, respect the patient’s right to know, ensure the integrity and accuracy of the medical record information, and safeguard the legal rights of both doctors and patients so that the medical record information is maximally available for social services.