The way to evaluate the timeliness of medical record filing is to conduct a comprehensive evaluation based on the monthly Medical Record Filing Status Monthly Report of the case room. Evaluation indicators include: 24-hour filing rate, 48-hour filing rate, 72-hour filing rate and so on.
1, weekday discharged medical records filing day calculation: the first page of the case of the discharge date + 72 hours.
2, holiday discharges of medical records filing day calculation: the date of discharge + the number of holiday days after the date of discharge + 72 hours.
Medical records are divided into three kinds:
1, inpatient medical records, the hospital shall not be less than 30 years, lost or damaged are the responsibility of the hospital;
2, outpatient medical records in the hospital to establish the file, the hospital shall not be less than 15 years;
3, outpatient medical records kept by the patient, including laboratory tests, checklists, registration ticket stubs, etc., these patients must be properly stored.
Consequences of falsifying medical records:
1, bear the corresponding civil liability;
2, falsification or tampering with medical records: medical records in the handling of medical disputes, certain personal injuries, civil and criminal cases have an important role in the litigation, such as the victim of the degree of injury is the severity of the victim is the victim whether to assume and what kind of legal responsibility is an important basis. Intentionally forged or tampered with medical records, change the degree of injury issued by the perjury, directly affecting the law on the severity of the sentence, which is already illegal, can seriously interfere with the judicial organs of the fair enforcement of the law.
3, from the administrative responsibility, the behavior is a serious violation of the Chinese people's **** and the State Practitioners Law, the relevant provisions. And the "Regulations on the Treatment of Medical Accidents" Article 58 medical institutions or other relevant institutions in violation of the provisions of these regulations, one of the following circumstances, the administrative department of health ordered to correct, given a warning; the responsible supervisory personnel and other directly responsible personnel shall be given administrative or disciplinary action according to the law; the circumstances are serious, by the original issuance of the department to revoke its certificate of practice or qualification certificate: alteration, forgery, Concealment, destruction of medical records information.
4, the preparation of false test results: mainly medical and technical departments, such as testing, pathology, CT and X-ray filming, ultrasound and other tests, issued purely false results for the establishment of the diagnosis of a particular disease or exclusion of the false basis.
5, the circumstances are serious, but also may be held criminally liable, there have been doctors because of making false certificates, intentionally issued the wrong identification, convicted of perjury.
In summary: hospital organizations should strengthen the management of medical certificates, especially the management of the seal. Medical certificates issued by doctors should be audited and stamped by a person, and registered in detail for inspection.
Legal basis:
"Medical institutions, medical records management regulations" Article 2
Medical records refers to the medical staff in the process of medical activities formed in the text, symbols, charts, images, slices and other information in total, including outpatient (emergency) clinic medical records and hospitalization medical records. Medical records are filed to form a medical record. Article XII outpatient (emergency) medical records by the medical institution, the medical institution shall receive the results of the examination and test results within 24 hours after the examination and test results into or into the outpatient (emergency) medical records, and at the end of each diagnostic and therapeutic activities within the first working day of the outpatient (emergency) medical records filed.
Article XIII of the patient hospitalization, inpatient medical records by the hospital district unified custody. Due to medical activities or work needs, hospitalized medical records must be taken away from the hospital district, should be designated by the hospital district special personnel responsible for carrying and custody.
Medical institutions should be in the hospitalized patient test results and related information within 24 hours after receipt of the inpatient record or entry.
After the patient is discharged from the hospital, the hospitalized medical record by the case management department or special (part-time) personnel to save and manage.
Article XIV of the medical institutions should be strict management of medical records, no one shall not alter the medical records, it is strictly prohibited to forge, conceal, destroy, seize, steal medical records.