谈病案复印中出现的问题及对策  

The Problems in Making Duplicatio of Medical Records and the Countermeasures

作　　者：黄英[1] 刘克新[1] 李玉宏[1] 

机构地区：[1]解放军总医院病案科,北京市100853

出　　处：《中国病案》2003年第8期15-16,共2页Chinese Medical Record

摘　　要：目的了解患者方面要求复印病例的原因和问题,研究制定相应政策。材料与方法:本院病案科复印资料2142份的调查表的数据分析。结果:复印原因中医疗保险公司需要占60.9％,后续治疗占22.6％,法律取证占8.4％,劳动保障占7.5％,而医疗纠纷占0.5％。复印中的主要问题是病案书写和管理问题,结论:完善病案复印管理规定,加强病案书写与管理,为患者提供可靠的复印材料。才能保护医患双方的权益。Object: to investigate the reasons why the patients want to duplicate their medical records and the problems in this aspect, so as to make relative policies. Method: 2142medical records that had been copied were analyzed. Result: among the cases, 60. 9% are for health insurance agent, 22. 6% for further treatment, 8. 4% for lawvissues, 7. 5% for labor security, and 0. 5% for medical disputes. Majority of the problems in coping medical records are caused by ill documentation and management. Conclusion: The hospitals are responsible for improving the management, documentation of medical records, and the policy of copying medical records.

关 键 词：病案复印 问题 对策 病案质量 病案管理 

分 类 号：R197.3[医药卫生—卫生事业管理]