A, medical institutions outpatient medical records retention period
The storage period of outpatient medical records in medical institutions should be no less than 15 years.
"Regulations on the Management of Medical Records of Medical Institutions" Article 28 Medical institutions may process and save paper medical records by using microform technology that meets the requirements of file management.
Twenty-ninth outpatient (emergency) medical records shall be kept by medical institutions for not less than 15 years from the date of the patient's last visit; The preservation time of in-patient medical records is not less than 30 years from the date of the patient's last hospitalization and discharge.
Second, the content of medical records
Medical records include outpatient medical records, inpatient medical records, medical accident files and death files. General hospital medical records are mainly divided into outpatient medical records and inpatient medical records, and medical accident medical records and death medical records are treated as special inpatient medical records.
(1) Outpatient medical records mainly include patients' medical records, outpatient laboratory sheets, X-ray examination reports, B-ultrasound reports, electrocardiogram reports and other records, as well as doctors' diagnosis conclusions and various treatment prescriptions, and also include the stubs of outpatient Chinese and western prescriptions.
(two) the general hospitalization medical records mainly include the hospitalization certificate issued by the outpatient doctor and the conclusion of the initial diagnosis; Various records, laboratory tests, X-rays, ECG, EEG, B-ultrasound, CT and other inspection records observed by doctors in inpatient departments and their diagnosis conclusions; Nursing staff's observation, treatment and nursing records of patients; Written materials such as preoperative consultation conclusion, surgical plan, surgical consent, anesthesia record sheet and intraoperative accident treatment plan produced by patients who need surgery.
(3) The medical accident file mainly includes the patient's condition, the doctor's treatment plan, all records formed during the treatment, and the appraisal conclusion and disability grade certificate of the accident appraisal committee after the accident. Some accidents also contain autopsy records formed by forensic doctors.
(four) the death file mainly includes all the records of rescuing patients, as well as the notice with the time and place of death.
Thirdly, the establishment and arrangement of medical records.
(a) all outpatients should establish outpatient medical records. Hospital outpatient service is the first visit of patients, and it is also the place where the most medical records are formed. Outpatient departments should fill in the outpatient medical record home page, medical record bag, patient name index card, medical record transfer card and registration card in detail. After the outpatient medical records are processed, the relevant departments should retrieve them in time and check their names, numbers and various reports. If the name and number do not match, it should be checked and corrected in time, and the correct medical records and various reports should be pasted neatly in order, put into the medical record bag and put on the shelves according to the serial number.
(two) all inpatients should establish a complete medical record. The admission management office is responsible for filling in the relevant contents on the first page of the inpatient medical records, the hospitalization number and the admission card, and sending the outpatient medical records and inpatient medical records to the ward together with the patients. When a patient is discharged from hospital or dies, the inpatient medical records are written by the attending physician, and the discharge records, summaries or death records are sent to the hospital management office by the nurse, and are recovered by the medical record room after the handover procedures. Medical record room managers should sort out the recovered medical records.
The order of hospitalization medical records is as follows: the first page of hospitalization medical records-discharge summary, death records and autopsy records, death notice-hospitalization medical records-admission records-course records (including transfer records, in chronological order)-nursing records-anesthesia records-operation records-consultation records-various inspection and laboratory reports (pasted neatly according to time and category)-long-term doctor's advice-temporary doctor's advice-special records (including physical therapy and medical treatment) of medical accidents.
(3) Arrangement requirements: when arranging medical records, check whether the medical records are complete, whether the natural conditions such as the patient's name, age, hometown, marital status, occupation and address on the first page of medical records are complete, and whether the length of hospitalization, diagnosis, prognosis and surgical healing meet the requirements. After being arranged in sequence, collect and bind the left side and the top, put them on the medical record shelves of various subjects, and put them on the shelves in turn according to the medical record number after being reviewed and signed by the superior doctors.
The above is the legal knowledge about "the shelf life of outpatient medical records in medical institutions" compiled and introduced by Bian Xiao, the legal express. Hospitals should do a good job in keeping medical records within the legal storage period. If the patient needs it, he can go to the hospital to copy the medical records, and the hospital should allow it. If you have any other legal questions, please consult the Legal Express, and we will have professional lawyers to help you.