病案借阅中存在主要问题及其对策  

The Main Problems in Medical Records Borrowing and Countermeasures

作　　者：王瑛霞[1] 

机构地区：[1]陕西省宝鸡市妇幼保健院

出　　处：《中国病案》2012年第3期13-14,共2页Chinese Medical Record

摘　　要：病案除了为医疗、教学、科研服务外,也被社会其他领域广为利用,如:医保病人报销、医患纠纷、商业保险理赔、工伤评残、办理病退、公检法办案取证等。使病案的借阅量明显增加,为防止病案丢失,涂改等,病案的规范化、制度化管理显得越来越重要,病案借阅的管理也成为重中之重。必须规范严格的病案借阅制度,确保病案及时完整的归档。病案管理人员必须建立完善精细的病案借阅管理制度,规范病案借阅手续,杜绝病案借阅中的违规行为,保护患者的隐私,维护病案的真实性、权威性和严肃性,保证医疗工作的正常运行。Except for medical, teaching and scientific service, medical records also are widely applied by other social circles, such as reimburse- ment for medical insurance patients, medk：al tangle, commercial insurance claim; injury suffered on the job for evaluation disable; dealing with retiring from office because of illness, getting evidence for public security bureau, precuratorate and court and. so on. Because of the obvious increase of borrow- ing amount of medical records, the standardization and systematization management of medical records are become more and more important for avoiding lost and modification of medical records; the management of medical records borrowing become the most important of it. We need to strictly standardize borrowing system for making sure the timely and complete filing of medical records. Managers of medical records should set up perfection and detailed borrowing management system of medical records and standardization of borrowing procedure, for eliminating violation behavior in borrowing in order to protect patients＇ privacy, maintain the truthfulness, authority and seriousness of medical records, which can gUarantee the normal operation of medi- cal work.

关 键 词：病案借阅 管理制度 对策 

分 类 号：R197.3[医药卫生—卫生事业管理]