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病案是医务人员对患者的诊断、治疗、检查、护理所做的客观真实的文字记录。由于种种原因,病案记录中患者姓名、既往病史年限等信息如果不准确或出现错误,则会造成医疗费用不能报销等经济或者法律问题,导致患者或家属要求医院更正姓名的现象,从而造成医疗工作混乱,同时增加了医院相关部门的工作量。因此,加强病案环节管理,认真核对患者个人信息,是杜绝此类错误和混乱的有效手段之一。同时,要严格审核,按程序办理患者姓名更正手续,避免引发其他相关工作的混乱和不必要的医患纠纷,维护医院的品牌质量和良好的社会形象。
A medical record is an objective and realistic record of the medical staff’s diagnosis, treatment, examination and care. Due to various reasons, if the information such as the patient’s name, past medical history and other information in the medical records is inaccurate or inaccurate, economic or legal problems such as medical expenses can not be reimbursed, resulting in the patient or family members requesting the hospital to correct the name, resulting in medical work Chaos, while increasing the workload of hospital departments. Therefore, to strengthen the management of medical records and check the personal information of patients carefully is one of the effective measures to stop such mistakes and confusion. At the same time, it is necessary to strictly examine and correct the patient’s name according to the procedures, to avoid causing chaos and unnecessary disputes between doctors and patients in other related work and to maintain the hospital’s brand quality and good social image.