论文部分内容阅读
病案属于科技档案之一,是医疗档案的重要组成部分。它不仅记载着病人住院期间的整个病情变化及治疗护理的全过程,而且其法律依据和凭证的作用,已受到越来越多的人的重视。因此搞好病案管理对医院的医疗、教学、科研等都有着重要的意义。本文就在实际工作中病案对外利用时经常遇到的一些问题,在此与大家一起进行探讨。 1 病案对外利用所涉及的范围 随着经济体制改革和生活水平的提高,人们法律观念和自身健康保护意识的增强,病案的对外利用已明显呈逐年上升的趋势,主要涉及以下几点: (1)因纠纷引起外伤入院治疗; (2)因交通事故引发的外伤; (3)意外损伤或重大疾病,曾参加社会医疗保险; (4)去外院就诊,需携带有关病案资料; (5)涉及计划生育方面的有关病案资料;
The medical record is one of the scientific and technological archives and is an important part of medical records. It not only records the entire change of the patient’s condition during hospitalization and the whole process of treatment and care, but also the role of its legal basis and vouchers has attracted more and more people’s attention. Therefore, improving the management of medical records has important implications for the hospital’s medical care, teaching, and scientific research. This article discusses some of the problems that are commonly encountered in the external use of medical records in practical work and is discussed here with everyone. 1 The scope of external use of medical records With the improvement of economic system reform and living standards, people’s awareness of legal concepts and their own health protection have been enhanced, and the external use of medical records has clearly been increasing year by year. The following are mainly involved: (1 (2) Injuries due to traffic accidents; (3) Accidental injuries or major illnesses, have participated in social medical insurance; (4) To go to a foreign hospital for medical consultation, you need to bring relevant medical record information; (5) Family planning related medical records;