病历管理手册.docx

博罗现代医院病历管理手册二OO九年五月目 录1、病历书写基本规范············································12、病案管理委员会及职责········································83、医院病历质量管理奖罚办法····································94、医院病历书写要求············································145、医院急诊科留观记录··········································266、急诊留住观察记录书写要求····································277、门诊病历书写要求············································288、病房医嘱书写、执行制度······································299、知情谈话告知制度············································3110、住院病人（或家属）知情谈话记录·····························3311、病历完成时限规定···········································3512、运行病历质量检查评价表（2008）······························3613、终末病历质量重度缺陷判定标准（2008修正版）··················3714、终末病历质量检查评分表（2008）······························3815、住院（终末）病历质量缺陷判定标准（2008）····················4116、14表和15表情况说明········································4417、住院病历首页填写要求与说明·································4718、住院期间病历排列次序·······································5119、出院（死亡）病历排列次序···································5220、关于“统一病历中时间书写格式”的通知·······················5321、关于统一使用碳素墨水书写病案文件的通知·····················5422、红笔使用规定···············································5523、住院病历归档制度···········································5624、病历查阅复印管理规定·······································5725、病历复印相关规定···········································5826、允许复印的病历资料包括的内容·······························58病历书写基本规范（试行）第一章?基本要求第一条　病历是指医务人员在医疗活动过程中形成的文字、符号、图表、影像、切片等资料的总和，包括门（急）诊病历和住院病历。 第二条?病历书写是指医务人员通过问诊、查体、辅助检查、诊断、治疗、护理等医疗活动获得有关资料，并进行归纳、分析、整理形成医疗活动记录的行为。 第三条?病历书写应当客观、真实、准确、及时、完整。 第四条?住院病历书写应当使用蓝黑墨水、碳素墨水，门（急）诊病历和需复写的资料可以使用蓝或黑色油水的圆珠笔。 第五条?病历书写应当使用中文和医学术语。通用的外文缩写和无正式中文译名的症状、体征、疾病名称等可以使用外文。 第六条?病历书写应当文字工整，字迹清晰，表述准确，语句通顺，标点正确。书写过程中出现错字时，应当用双线划在错字上，不得采用刮、粘、涂等方法掩盖或去除原来的字迹。第七条?病历应当按照规定的内容书写，并由相应医务人员签名。 实习医务人员、试用期医务人员书写的病历，应当经过在本医疗机构合法执业的医务人员审阅、修改并签名。 进修医务人员应当由接收进修的医疗机构根据其胜任本专业工作的实际情况认定后书写病历。第八条?上级医务人员有审查修改下级医务人员书写的病历的责任。修改时，应当注明修改日期，修改人员签名，并保持原记录清楚、可辨。 第九条　因抢救急危患者，未能及时书写病历的，有关医务人员应当在抢救结束后6小时内据实补记，并加以注明。 第十条?