The patient has the right to request a copy or reproduction of his or her outpatient medical records, hospitalization records, temperature slips, doctor's orders, laboratory tests (test reports), medical imaging data, special examination consent, surgical consent, surgical and anesthesia record slips, pathology data, nursing records and other objective medical records. Medical institutions shall provide copying or reproduction services and photocopying or reproduction of medical records stamped with the seal of proof. The patient has the right to be present when the medical records are copied or reproduced. In the event of a medical malpractice dispute, the record of the discussion of the death of the case, the record of the discussion of the difficult cases, the record of the superior physician's examination, the consultation opinion, the record of the course of the disease, and other subjective medical records shall be in the presence of both the patient and the doctor to seal and unseal the case. Sealed medical records may also be copies, which are kept by the medical institution.
Legal objective:The patient to the hospital to request a copy of the medical records need to pay attention to matters a need to submit to the medical department of the hospital to copy or copy the application of the medical records of the Ministry of Health [2002] No. 193, "Medical Records Management Regulations," Article 12 provides that: medical institutions shall accept the following persons and institutions to copy or copy the application of the medical records of information: ① the patient himself or her agent; ② deceased patient's next of kin or his agent; ③ insurance agencies. Ministry of Health [2002] No. 193, "Medical Records Management Regulations," Article 13: Medical institutions should be responsible for quality control of medical services by the department or full-time (part-time) staff responsible for accepting the application for copying or reproducing medical records. According to the above regulations, the hospital accepts the application for copying or reproduction of medical records is generally the medical department, the patient requests copying or reproduction of medical records, should be made to the hospital medical department to submit the appropriate application. Second, the patient to the hospital to copy or copy the medical records of the materials to be submitted to the Ministry of Health [2002] No. 193, "Medical Records Management Regulations," Article 13 provides: medical institutions to accept the application for copying or copying of medical records, the applicant should be required to provide relevant materials in accordance with the following requirements: ① applicant for the patient himself, should provide his valid identification; ② applicant for the The patient's agent, should provide the patient and his agent's valid proof of identity, the applicant and the patient's agent relationship with the statutory documents; ③ applicant for the death of the patient's next of kin, should provide proof of the death of the patient and his next of kin's valid proof of identity, the applicant is the death of the patient's next of kin of the statutory documents; ④ applicant for the death of the patient's next of kin agent should provide proof of the patient's death, death The applicant is the agent of the deceased patient's next of kin, should provide the patient's death certificate, the valid identity of the deceased patient's next of kin and his agent, the deceased patient and his next of kin's relationship with the legal documents, the applicant and the deceased patient's next of kin agent relationship with the legal documents. Third, the patient has the right to photocopy the contents of medical records for verification, the medical institution should be stamped with a seal of proof Ministry of Health [2002] No. 193, "Medical Records Management Regulations," Article 17 provides that: the medical institution accepts the photocopying or copying of medical records after the application, by the department responsible for monitoring the quality of health care services, or a full-time (part-time) staff notification of the department responsible for maintaining outpatient (emergency) clinic medical records (personnel) or patient area, the outpatient (emergency) clinic medical records will be kept by the department (personnel) or patient area, and the patient will be given a certificate of death. ) or ward, the medical records to be copied or reproduced within a specified period of time to the designated location, and in the presence of the applicant to copy or reproduce. After the photocopied or reproduced medical records have been checked by the applicant for accuracy, the medical institution shall affix a certification seal. According to the above regulations, the applicant has the right to check the content of the medical records that have been photocopied or reproduced by the hospital. The applicant has the right to request the medical institution to make copies of the medical records that should be copied but the medical institution fails or refuses to do so. Fourth, how to determine the patient in the hospital process of what laboratory tests and imaging tests patients are discharged from the hospital and the hospital after the settlement of fees have a list of fees, the list of fees can clearly show the patient in the hospital or medical treatment during the specific time of the specific tests, the patient can be based on this to the hospital to request copies of the specific medical record information. Another suggestion: the patient to the hospital to request a copy of the medical records, can be based on the above legal provisions and the cost list to make a copy of the specific medical records of the list, after copying the list can be based on this list of audit of the hospital in accordance with the legal provisions of the copy of the medical records of the information.