对一起未按规定保管病历资料案的分析与思考  

Analysis and Consideration of a Case of Failing to Keep Medical Records According to Regulations

作　　者：任洁 葛安凤 任涛 REN Jie;Ge An-feng;REN Tao(Chaoyang District Health Supervision Institute,Beijing 100021)

机构地区：[1]北京市朝阳区卫生健康监督所,北京100021

出　　处：《中国卫生监督杂志》2022年第3期282-284,共3页Chinese Journal of Health Inspection

摘　　要：本案是一起由医疗纠纷投诉而对某医院开展病历书写、保管、封存过程的全面调查,最终因检查结果未在24小时内归入住院病历导致被行政处罚的典型案例。作者通过对该案件查办过程的分析,总结调查技巧、违法行为认定、法律适用等方面的经验,针对病历资料保管监督执法和法律修订提出建议,为卫生行政执法工作提供借鉴和参考。This is a typical case of a hospital conducting a thorough investigation into the writing,keeping,and sealing of medical records in response to a complaint about a medical dispute,and ultimately receiving administrative punishment because the examination results weren't entered into the inpatient medical records within 24 hours.Through the analysis of the investigation process of the case,the author summarized the experience of investigation skills,determination of illegal acts,and application of law,and put forward suggestions for the supervision of medical records keeping,which could provide reference for the law enforcement of health administration.

关 键 词：病历管理 病历保管 医疗纠纷 

分 类 号：R197[医药卫生—卫生事业管理]