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- 2017-10-13 发布于河南
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病案室管理制度(Management system of medical record room)
病案室管理制度(Management system of medical record room)
Summary
1, the hospital must establish a medical record room, is responsible for the total station medical records (outpatient, inpatient) collection, collation and storage work. ? Xml:namespace prefix = o ns = urn:schemas-microsoft-com:office:office /
2, outpatient and inpatient patients should have complete medical records. The room should be timely recovery and check is complete, at the same time to fill in the index, in order, binding, archiving number.
3, this station doctor borrows the medical record, must go through the loan procedure, after reading, returns on time. To borrow the medical record should be kept properly and care, shall not be altered, lent, dismantled and lost, outside the unit shall not borrow. When the public security and judicial departments need to have the letter of recommendation, they may, by the consent of the medical department, extract medical history or copy if accompanied by the medical department.
4, hospitalized medical records should be kept in principle for a long time.
Edit the responsibilities of the medical record manager
1, under the leadership of the chief of medical work.
2, often check the medical records written in each case, and put forward suggestions for improvement, improve the quality of medical records writing.
3. Responsible for the collection, collation, binding, filing, examination and storage of medical records.
4. Responsible for indexing, registering and cataloging medical records,
5. Find the case number of the patients who are re hospitalized and return to the clinic to ensure the supply of medical records and apply for medical records.
6, provide teaching, scientific research, clinical experience, summary of the use of medical records.
7, do a good job in the management of the medical record room. Keep clean and tidy, ventilated, dry, prevent medical mildew, moth and fire.
Edit this paragraph specific provisions
First, the medical records management regul
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