病案统计室规章制度（Medical record statistics room rules and regulations）.doc

病案统计室规章制度（Medical record statistics room rules and regulations） 二十亿二千七百二十六万零二百五十九 conglinlang 【病案统计室】病案管理工作制度 一、信息科病案室负责全院病案的保存与管理工作。 二、加强病案管理，保证病案资料客观、真实、完整。 三、严格病案管理，严禁任何人涂改、伪造、销毁、抢夺、窃取病案。 四、除本院医务人员、科研人员及医疗科、质管科等相关人员外，其他任何机构和个人不得擅自查阅患者的病案。 五、公安、保险、司法部门因办理案件，需要查阅、复印病案，须由公安、保险、司法部门出具法定证明及执行公务人员的有效身份证明后予以协助办理。 六、发生医疗事故争议时，由医疗科负责人在患者或代理人在场的情况下封存患者病案讨论记录、疑难病案讨论记录、上级医生查房记录、会诊意见、病程记录等封存病案由医疗科专人负责保管，封存病案可以是复印件。 七、病案库房应保持清洁，保存病案的场所应符合国家档案局规定的基本要求，病案存放应整齐有序； 八、病案室应备有消防灭火器材，禁放易燃物品，禁止吸烟；采取防鼠、防蛀、防尘、防强光等病案保护措施。 【病案统计室】病案收集和整理工作制度 一、病案由病案室集中统一管理， No department, organ or individual may keep the medical records, and the medical record room shall ensure the systematization and integrity of the medical records. Two, the medical record room is responsible for the collection, collation, archiving, storage, statistical analysis and other work of medical records. Three, the filing time of medical records: after the patient leaves the hospital (the death), each department should send the medical record to the discharge examination office in time. Medical records were collected by medical records room within 24 hours after discharge. Four, after receiving the medical records, the medical records should be collated and carefully checked to see whether the medical records are complete. Whether the medical record data are arranged in accordance with the requirements, such as missing or incomplete records and the Department shall promptly contact Buji truthful. Five, medical records filing requirements complete and accurate, handwritten parts should be neat and clear, in line with hospital regulations. Six, all archived medical records require doctors at all levels to complete before archiving, who can not be completed without filing in time. Seven, the time limit to record the registration filing, according to the standard for evaluation into the overall quality of the medical record and included in the assessment of 1000. [medical record statistics] medical record lending system First, the