Hospital medical records file archiving process
Medical records file referred to as the case, also known as medical records, refers to the medical staff of the patient's disease diagnosis and treatment process of the formation of text, symbols, charts, images, slices and other information in total, it is objective, complete, continuous record of the patient's condition and diagnosis and treatment of the patient through the clinical diagnosis of the scientific treatment of the basis of the information is to safeguard the rights of doctors and patients. It is an important basis for safeguarding the rights and interests of doctors and patients. The following I organized for you to hospital medical records file process related content, I hope to help you!
First, the content of the medical records file
The medical records file includes outpatient medical records, hospitalization medical records file and medical malpractice files, death files, and other four aspects. General hospital medical records are mainly divided into outpatient medical records and inpatient medical records of 2 categories, and medical malpractice medical records and death medical records as a special hospitalization records.
(a) outpatient medical records mainly include the patient's medical records, outpatient laboratory tests, X-ray reports, ultrasound reports, electrocardiogram reports and other records, as well as the doctor's diagnosis of the conclusion of the various treatments prescribed, including outpatient Chinese and Western prescription stubs.
(b) General inpatient medical records mainly include the hospitalization certificate issued by the outpatient doctor and the conclusion of the initial diagnosis; the inpatient doctor's observation of various records, laboratory reports, X-ray films, electrocardiograms, electroencephalograms, ultrasound, CT and other examination records and their diagnostic conclusions; the nursing staff of the patient's observation, treatment and care of the various records made; the need for surgery, such as the pre-operative consultation of the patient to produce Conclusion of preoperative consultation, surgical program, surgical consent, anesthesia record sheet, the handling of intraoperative accidents and other written materials.
(C) medical malpractice files mainly include the patient's condition and the doctor's treatment plan, the process of medical treatment of all the records, as well as accidents, the accident appraisal committee's findings, disability rating certificate, some accidents also contain forensic autopsy of the formation of the autopsy transcripts.
(d) death file mainly includes all the records of the rescue of patients, as well as write the time of death, location and other content of the notice.
Second, the establishment and organization of medical records
(a) All outpatients should be established outpatient medical records. Hospital outpatient is the patient's first visit, but also the formation of the largest number of medical records files, outpatient department should be filled out in detail outpatient medical records home, medical records bag, patient name index card, medical records for transfer card, registration card. Outpatient medical records for the end of the relevant departments should be retrieved in a timely manner, and check the name, number and a variety of report cards, such as the name, number, inconsistent with the corrections should be checked in a timely manner, will be error-free medical records and a variety of report cards in accordance with the order of the position of the paste neatly into the medical records bag, according to the number of sequential arrangement of the shelves to be preserved.
(2) All hospitalized patients should establish a complete hospitalization medical record. Inpatient medical records by the admission and discharge management office is responsible for filling out the inpatient medical records of the first page of the relevant content, hospitalization number and admission card, will be outpatient medical records, inpatient medical records together with the patient sent to the ward. When a patient is discharged or dies, his/her inpatient medical record shall be written by the attending physician for the discharge record, summary or death record, and sent to the Admission and Discharge Management Office by the nurse, and retrieved uniformly by the case room after going through the handover procedures. The case room managers should sort and organize the recovered medical records.
Inpatient medical record materials are sorted as follows: inpatient medical record home page - discharge summary, death records and autopsy records, death notification form - inpatient medical history - admission records - medical records (including transfer handover records, in order of date) Nursing records - Anesthesia records - Surgery records - Consultation records - Various examination and laboratory reports (neatly pasted according to time and type) - Long-term medical orders -Temporary medical advice -Special records (including records of physical therapy, radiation therapy, Chinese medicine, acupuncture, and other treatments) -Temperature charts (i.e., temperature, pulse, respiration record sheets), etc. Medical malpractice medical records, should also be attached to the accident appraisal committee's conclusions, disability rating certificate, autopsy formation ` cadaver investigation transcripts and other materials.
(C) finishing requirements: in organizing the medical records file, you should check whether the medical records are complete, there is no alteration unclear, the first page of the medical records of the patient's name, age, place of origin, marital status, occupation, address, and so on whether the natural situation is complete and complete, the number of days of hospitalization, diagnosis, transfer and surgical healing and other items in line with the requirements. In order to arrange a good, the left side and the upper side of the take Qi binding, placed in the medical records of various departments on the shelf, on behalf of the superior physician audit signature, according to the medical record number on the shelf in order to save.
Third, the number of medical records
The beginning of the patient's visit, the hospital will be given to the patient number, in order to establish the medical records. The hospital to the patient assigned number is independent, the patient in the process of diagnosis of all the materials produced by the record of this number. Currently more commonly used medical records file number:
(a) unified numbering method: outpatient medical records, inpatient medical records (including medical malpractice and death records) unified pull-through number. The advantage of this method is that each case is only a number, a hospital only a set of patient name index, to avoid confusion due to outpatient medical records and inpatient medical records and the difficulties caused by the search and archiving.
(B) two centralized system: outpatient medical records and inpatient medical records were numbered according to two systems, when the patient was hospitalized in the original outpatient medical records into the inpatient medical records, the patient was discharged from the original outpatient review or re-hospitalization, are based on the inpatient number to find the medical records, the original outpatient number that will be null and void or stay empty number to other outpatients use.
(C) two separate system: that is, outpatient medical records and inpatient medical records are numbered and managed separately. Suitable for outpatient clinics, inpatient department examples of hospitals farther away.
Fourth, the duration of custody of medical records
According to the Ministry of Health, "the national hospital work regulations, the hospital work system and the duties of the hospital staff," the provisions of the "inpatient case in principle, permanent preservation". Therefore, the majority of hospitals on the medical records file storage period is divided into the principle of: inpatient cases identified as preservation, outpatient medical records identified as 30 years. Full 30 years of medical records file by the case management committee to identify the decision to deal with the valuable continue to save, no value after the registration to be destroyed.
Fifth, the hospital how to open the case
open the sick leave certificate, should go to a qualified regular hospital, first of all, according to the specific disease hang up the number of different departments, by the outpatient doctor to confirm the diagnosis of the disease, to provide treatment programs. The first thing you need to do is to ask the doctor to issue a diagnostic certificate and stamp it.
General hospitals are required to go to the hospital to check the treatment to give the certificate, if you do not go through the hospital diagnosis and treatment, general doctors and hospitals are not to give the certificate.
Six, medical records:
Including diagnostic certificates, is the occurrence of the patient's disease, the development of the patient's return to the examination, diagnosis, treatment, and other medical activities in the process of record. It is also the collection of information to be summarized, organized, comprehensive analysis, according to the prescribed format and requirements written by the patient's medical health records.
The medical record is a summary of clinical practice, but also to explore the law of disease and the legal basis for dealing with medical disputes, is a valuable asset of the country. Medical records have an important role to play in medical treatment, prevention, teaching, research, and hospital management.
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