Detailed rules for the administration of medical record filing 1
A, discharge medical records filing management regulations
(1) After the patient was discharged from the hospital, all medical records were immediately sent to the inpatient department for discharge formalities.
(two) part of the medical records, pathological reports and laboratory test reports are still not returned, and the medical records should be filed. After the results come out, they should be returned to the medical record room to complete the medical records.
(3) The medical records of deceased patients are also filed according to the above requirements. When discussing death cases, departments should borrow medical records from the medical record room again and implement the relevant provisions in the Medical Record Lending System.
(four) medical record room staff at any time to the inpatient department for medical record recovery, and completes the registration and signature procedures.
(5) Each ward shall sort out the patient's medical records before discharge, and the ward staff shall send them to the inpatient department to fill in the handover record, which shall be signed by both parties.
(6) All archived medical records shall be signed by resident, attending physician and quality control physician before archiving. Can't fill in, according to the medical records not filed in time.
(seven) failed to file medical records into the overall evaluation of medical record quality, informed the floor and the corresponding bonus and salary punishment.
(8) If the medical record is lost, the relevant responsible person 1 1,000 yuan will be deducted. For medical disputes caused by the loss of medical records, the responsible person shall bear other responsibilities caused by the loss of medical records.
Second, the medical record borrowing regulations
(a) medical records belong to the special archives of the hospital, and the closed management mode is implemented.
(two) patients have no right to borrow and carry my medical records.
(3) Other medical institutions have no right to borrow hospital medical records.
(4) All lent medical records must be returned within 3 days. If they need to be used again, they should be updated. Among them, the medical records of medical department, quality control, medical insurance and agricultural cooperative audit should be returned on the day after the inspection.
(six) the medical records shall be managed in a closed way, and according to special requirements, limited borrowing shall be carried out in the following four cases. The principle is that only archived medical records can be borrowed, and unfilled medical records cannot be borrowed.
1. When the attending doctor of the hospital reads the medical records of the re-admitted patients, the borrower must be the attending doctor. If you are a non-attending doctor or internship (training) doctor, you must have an iou signed by the attending doctor before you can borrow it.
2. When discussing clinical teaching or death (difficult) cases, the borrower must be a physician in the department where the patient died (critically ill or difficult). If he is an intern or a refresher doctor, he can borrow it after double signing.
3. If it is necessary to borrow medical records under special circumstances, the borrowing application form stamped by the Medical Department can be borrowed unilaterally.
4. If the medical record is perfect, it must be returned within 3 days, otherwise it will be treated as an unfilled medical record, and it will be notified and punished with corresponding bonuses and wages (for more than 7 days, the party concerned will be fined 100 yuan every day until it is returned.
Seven, except for the four cases stipulated in Article 6, all medical records shall not be lent to the medical record room, including the following situations:
1, the nursing department and nurses (supervisors) in various wards conduct quality control inspection on nursing records.
2, pharmacy department to consult relevant information.
3, medical insurance, agricultural cooperation, medical care, quality control and other inspections (as far as possible in the medical record room).
4. Copy all medical records.
5. Postgraduate research needs to be signed by the teaching doctor (official staff of the hospital)
The application for word access is only allowed in the medical record room, and the access person must be a participant in the project, and each access shall not exceed 20 copies.
6. When doctors in our hospital need to consult medical records for scientific research, they are only allowed to do it in the medical record room, and they can only consult the medical records of patients they have treated.
8. Other unspecified circumstances.
(8) Borrowed medical records should be properly kept, and it is forbidden to alter, disassemble, lose, lend to others, take them out of the hospital, copy or duplicate them. If there is such a situation, after verification, the party concerned will be investigated for responsibility according to law and given corresponding punishment.
These Provisions shall be implemented as of the date of promulgation.
Detailed rules for the administration of medical record filing II
Chapter I General Provisions
Article 1 These Provisions are formulated to strengthen the management of medical records.
Article 2 Doctors should write medical records and sign them in strict accordance with the Basic Specification for Medical Records Writing issued by the Ministry of Health and state administration of traditional chinese medicine.
Article 3 Resident doctors are responsible for writing medical records, and attending doctors are responsible for reviewing medical records. Special circumstances are written by the attending doctor at or above the department level. Interns can't write admission records instead of residents, and their course records and medical records written by senior doctors and graduate students must be reviewed and signed by our superior doctors. The director is the person in charge of medical record management. The medical department is responsible for the supervision and inspection of medical record management.
Chapter II Basic Requirements of Medical Record Inspection and Management
Article 4 Fill in the Checklist of Outpatient Medical Records of Beijing Hospital on time. Each department director should check at least 0 copies of undergraduate medical records 10 every quarter to understand the writing situation of medical records and strengthen the management of medical records writing.
Article 5 The Medical Department shall organize experts to inspect each discharged medical record, establish professional technical files, and record the examination of medical record writing as the basis for selecting advanced and promoted professional titles.
Article 6 Key points of medical record examination
(1) Whether the medical record writing is true, clear and accurate.
(two) whether the record is completed within the prescribed time limit.
1 Completion time of various records
Admission records should be completed within 24 hours after the patient is admitted to the hospital.
The first course record was completed within 8 hours after the patient was admitted to the hospital.
The discharge record should be completed within 24 hours after the patient leaves the hospital.
The death record is completed within 24 hours after the death of the patient.
Operation records shall be completed by the operator within 24 hours after operation.
The rescue record shall be truthfully supplemented within 6 hours after the rescue and marked.
2 course recording time
Critically ill patients should record the changes of their condition at any time, at least once a day, and the recording time is in minutes.
Severe patients should record the course of disease at least every 2 days.
Patients with stable condition should record the course of disease at least once every 3 days.
The course of disease should be recorded before operation and the day before discharge.
The patient's course record should reflect the patient's preoperative condition.
Before and after the operation, the anesthesiologist checked the patient's records.
The course of disease was recorded at least once a day for the first three days after operation.
Patients who have been hospitalized for more than one month must make a summary of their illness once a month.
When the patient's attending doctor changes, he/she must write the handover and handover records.
3 superior physician rounds record
Within 48 hours of admission, the patient must have the attending physician's rounds and preliminary diagnosis and treatment opinions.
Within 72 hours after admission, the patient must have a doctor with deputy director or above to make rounds and make preliminary diagnosis and treatment suggestions.
Difficult patients must have records of rounds and case discussions of doctors above the deputy director.
Critically ill patients should have a superior doctor's rounds record every day.
Seriously ill patients have a superior doctor's ward round record for at least 3 days.
Patients with stable condition must have a superior doctor's rounds record within 5 days.
4. Need surgery, special examination and treatment should have informed consent.
Article 7 All clinical departments, department directors and medical departments should conscientiously do a good job in the review of link medical records and the quality inspection of final medical records, and the department directors should strengthen the spot check of link medical records. Before the medical records are returned to the medical record room, the medical record committee member or attending physician is responsible for conducting a comprehensive examination of the medical records and filling in the checklist, which will be filled in together with the discharged medical records and recovered by the medical record room. The Medical Department organizes experts to evaluate the quality of medical records.
Article 8 The Medical Department shall report the medical record management of all subjects within a certain range every quarter.
Chapter III Reward and Punishment of Medical Records Examination Results
Article 9 For every B-ultrasound medical record, the bonus 200 yuan shall be deducted; 800 yuan will be deducted from each C-level medical record. The director of the department will punish the individual according to the responsibility of the doctor's medical record defects.
Article 10 Those who have one class C medical record or three class B medical records within one year will also be treated as follows.
(1) Attending physician and above: The hospital delayed hiring the newly promoted technical title for one year.
(2) Resident: delay one year to enter the next stage of training.
(3) Postgraduates: cancel the residency qualification.
(four) advanced students: cancel the qualification of advanced students, not to issue a certificate of completion.
(five) to inform the person in charge of the department where the party is located.
Eleventh other defective medical records into thousands of management points.
Article 12 Check and score the final medical record quality.
Those who score the top 3 will be rewarded with 2000 yuan for doctors in the treatment group and 0/000 yuan for departments/kloc. If you complete 3 points, each subject will be deducted 2000 yuan.
Thirteenth departments with C-level medical records or 3% B-level medical records throughout the year cannot participate in the selection of advanced departments and advanced party branches.
Chapter IV Supplementary Provisions
Article 14 Definition of Class B Medical Records
One of the following major quality defects is Class B medical records.
(1) The medical information on the home page is not filled in.
(2) Missing report of infectious diseases.
(three) the first visit record is missing or the first visit record lacks the main diagnosis basis, differential diagnosis and treatment plan.
(4) Lack of the diagnosis and treatment plan (or surgical plan) signed by the attending and higher-level doctors.
(five) during the hospitalization of critically ill patients, the director or deputy director of the lack of patient rounds.
(6) Lack of surgical records.
(seven) the death case lacks the record of rescue before death.
(eight) the lack of discharge records or death records.
(nine) to carry out new surgery (technology) and large-scale surgery without the signature of the director or authorized superior doctors.
(ten) the lack of invasive examination (treatment), surgical consent or the lack of patient (client) signature.
(eleven) the lack of auxiliary inspection reports that play a decisive role in diagnosis and treatment.
(twelve) there is evidence to prove that the medical record is a principled error caused by copying behavior.
(thirteen) the lack of a full page of medical records caused by incomplete medical records.
(14) has obvious changes.
(fifteen) imitate others or sign for others in the medical record.
Article 15 Definition of Class C medical records. The final medical record lacks admission records (written by interns is regarded as lacking admission records) or there are more than three defects listed in Article 14 of these Provisions.
Article 16 The link of medical record review refers to the review of key links of medical records while patients are still in hospital.
Seventeenth final medical record quality inspection refers to the comprehensive inspection of medical records before filing in the medical record room.
Article 18 These Provisions have been revised, adopted and implemented since 20xx 654381October 8.
Article 19 The Medical Department shall be responsible for the interpretation of these Provisions.
Detailed Rules for the Administration of Medical Records Filing III
First, our hospital temporarily implements a 72-hour filing system for medical records. That is, the patient's medical records will be classified into the medical record room within 72 hours after discharge.
Second, the time-limited evaluation method of medical record filing is based on the monthly report of medical record filing in the medical record room. Evaluation indicators include: 24-hour filing rate, 48-hour filing rate and 72-hour filing rate.
Three. Calculation formula of declaration date: (Take 72-hour declaration time as an example)
1, filing date of discharged medical records on weekdays: discharge date on the first page of medical records +72 hours.
2. Calculation of filing date of holiday discharge medical records: discharge date+holiday days after discharge date +72 hours.
Fourth, the medical record filing adopts the method of combining sending and receiving.
1, the staff in the medical record room regularly go to the ward to collect the discharge medical records, which shall be signed by both parties. After the medical records are retrieved by a special person in the medical record room, the hospitalization number is entered in the computer on the same day to sign and register.
2, the medical records sent by the ward, arranged by the department chief resident or chief resident undergraduate course room doctor sent to the medical record room for electronic signature filing. After signing, the medical record room prints the handover form, which is signed by the receiver and the sender and kept by the chief resident.
3, the medical record room is responsible for collecting medical records regularly. After receiving the phone call for medical record collection, the department doctors will send the medical records that have not been filed in time to the medical record room within 3 days.
4. When receiving the filed medical records, the staff in the medical record room shall have the right to reject the medical records with missing pages, missing items, incomplete filling and serious defacement, and send them to the medical record room on the same day after being perfected by the department.
Five, the treatment group is responsible for the quality management of medical records before filing, focusing on the following links:
1, completeness and arrangement order. First of all, we should check and ensure the integrity of 15 basic medical records, such as the first page of medical records, discharge summary, case discussion records, admission records, course records, notification consent, surgical documents, consultation sheets, nursing documents, special report stickers, imaging examination reports, laboratory tests, doctor's orders, temperature sheets, infection tables, etc., and sort them out according to the basic norms of medical record writing.
2, check the doctor-patient communication and the integrity of all kinds of informed consent. Before filing medical records, department doctors should check whether all kinds of notification consent forms are complete and fill in the missing ones in time according to the characteristics of undergraduate course and the contents of this diagnosis and treatment.
3. Ensure the integrity of inspection and test reports. Before filing medical records, doctors should check all kinds of tests and laboratory tests one by one according to the doctor's advice. Reporting departments that are not classified as medical records should set up fixed places for classified storage.
4. Ensure the integrity of nursing records. Before filing medical records, the nursing department should control the integrity and quality of nursing evaluation, notification, nursing record sheet, monitoring sheet, temperature sheet and other documents, and sort them according to the recording time.
Six, the medical record has been filed, but there is no inspection report, first file the medical record, and indicate the name of the omission in the upper right corner of the medical record cover with a pencil. After the report comes out, it will be sent to the medical record room on the same day.
Seven, the inspection report filed by the department in the later period is sent to the medical record room. If the medical record is not bound, it will be directly put (posted) into the medical record by the sender. If the medical records have been bound, the medical records shall not be opened in principle; The department must write a report explaining the reasons for late departure, which shall be signed by the department director and submitted to the medical department for examination and approval;
After examination and approval by the medical department, it shall be submitted to the medical record room for supplementary medical records. The inspection report submitted to the medical record room should be handed over for registration.
Eight, medical record room staff found missing items in the process of sorting out medical records, should promptly notify the director of the resident. The chief resident will improve the defect medical record in time on the day of answering the phone. The medical record room registers the lost items.
9. Before filing medical records, if patients need to copy medical records, they must meet the following two conditions, otherwise the medical record room will not copy them: 1, and the photocopier has complete certificates; 2, medical records meet the quality requirements of the archived medical records.
For those who meet the requirements for copying, the undergraduate doctor will accompany the patient to the medical record room to copy and bring it back to the department. Departments shall not give medical records to patients, and shall not take medical records to the hospital for copying without permission; Otherwise, all consequences will be borne by the department.
Ten, medical records before filing, medical records need to be sealed because of medical disputes, should first improve the contents of medical records, and then sealed, sealed pieces to the medical record room for preservation. After the medical records are unsealed, the department should sort out the medical records and file them.
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