病史记录在商业医疗保险理赔中的问题与对策研究  

Problems and Countermeasures of Medical Records in Commercial Medical Insurance Claims

作　　者：沈芳妮[1] 焦峰[1] 李小莹[1] Shen Fangni;JiaoFeng;Li Xiaoying(Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院

出　　处：《中国病案》2019年第12期25-27,共3页Chinese Medical Record

摘　　要：对某医疗机构2018年期间发生的患方或保险公司向病案主管职能部门提出的病史修改诉求28例进行分类,梳理各个诉求发生的事由和目的以及修改内容等。修改诉求主要集中在主诉病史部分,且无明确的修订依据,多数是出于商业保险理赔原因,即经济利益驱使。同时,由于病史采集、和不同人群对病史的理解认知的差异等原因,引发了病史修改诉求。为了解决此类问题,可通过培训、患方认可主诉并签字等方式,提高病史记录的客观真实性。通过明确病案内涵及用途,提高病案记录质量,增强病史记录客观真实性,维护各正当权益和医疗保障体系。Classified 28 cases of medical history modification claims made by the patient or insurance company to the competent functional department of medical record during 2018, and sorts out the causes, purposes and modification contents of each claim. The appeal for revision mainly focuses on the medical history of the main complaint, and there is no clear basis for revision, most of which is driven by the commercial insurance claims, i.e. economic interests. At the same time, due to the collection of medical history and the difference of understanding and cognition of different people on medical history, the appeal of medical history modification is triggered. In order to solve these problems, the objective authenticity of medical history records can be improved by means of training, patient’s approval of the chief complaint and signature. By clarifying the connotation and purpose of medical records, improving the quality of medical records, enhancing the objective authenticity of medical records, and maintaining the legitimate rights and interests and medical security system.

关 键 词：病史 商业医疗保险 理赔 

分 类 号：R197.323[医药卫生—卫生事业管理] F842.684[医药卫生—公共卫生与预防医学]