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目的精神病专科医院的门诊病案需要长期保存是它的特殊性。我院门诊病案保存时限最长已达60年仍在使用,库存340,000份,日门诊量1000余人,意味着每日建立新的门诊病案与查找病案次数。近年来,不少患者因伤残评定、医疗保险而查找首次门诊病案,充分证实门诊病案的作用。由于忽略对门诊病案质量的重视,管理上存在疏漏,示踪流通不畅,病案重号或丢失,给查找和利用带来困难,影响患者使用,造成医患纠纷。因此,加强门诊病案质量管理不可忽略。
The purpose of psychiatric hospital outpatient medical records need to be preserved for a long time is its particularity. The outpatient medical record in our hospital has been used for up to 60 years, with 340,000 stocks and over 1,000 daily outpatient visits, meaning daily setting up new outpatient medical records and searching for medical records. In recent years, many patients find the outpatient medical record for the first time because of disability assessment and medical insurance, which fully substantiates the role of outpatient medical record. Due to the neglect of the quality of outpatient medical records, there are omissions in management, poor tracing of tracing cases, heavy cases or loss of medical records, which have caused difficulties in finding and using patients, affecting patients’ use and causing disputes between doctors and patients. Therefore, strengthening the quality management of outpatient medical records can not be ignored.