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目的保证病案资料的完整性,维护医患双方的合法权益。方法对我院病案科报告单回收登记本上登记的2005年10月1日至2006年3月31日所有未及时归档的检查检验报告单进行统计分析,找出问题并分析存在原因。结论经过不断地了解原因,改进工作,不但提高了住院患者检查检验报告单的归档速度,最关键是保证了病案资料的完整性。
Objectives To ensure the integrity of medical records and safeguard the legitimate rights and interests of both doctors and patients. [Methods] Statistical analysis was performed on all inspection and inspection reports that were not filed in time from October 1, 2005 to March 31, 2006 registered on the registration form of the medical records section of our hospital. The problems were identified and the reasons were analyzed. Conclusion After constant understanding of the reasons and improvement of work, not only has the rate of filing an examination report for inpatients been improved, but the key is to ensure the integrity of the medical records.