Current location - Quotes Website - Personality signature - Reward and punishment system for medical record writing
Reward and punishment system for medical record writing
Legal analysis: Prescription writing must follow the writing format issued on February 25th, 20 1 165438, and the doctor's signature must be standardized, with clear and neat handwriting and easy identification. The functional departments of the hospital will conduct regular or irregular inspections. In case of violation, 5 yuan will be fined for each prescription. Those who pass the review and reach Grade A medical records will be awarded 10 yuan, and those who fail will be fined 10 yuan.

Legal basis: Regulations on Medical Records Management of Medical Institutions

Seventeenth medical institutions shall accept the following personnel and institutions to copy or consult medical records, and provide medical records copying or consulting services in accordance with the provisions:

(1) The patient himself or his entrusted agent;

(2) the legal heir of the deceased patient or his agent.

Eighteenth medical institutions shall designate departments or full-time (part-time) staff to be responsible for accepting applications for copying medical records. When accepting an application, the applicant shall be required to provide relevant certification materials, and the application materials shall be formally reviewed.

(a) if the applicant is the patient himself, he shall provide his valid identity certificate;

(2) If the applicant is the patient's agent, it shall provide the valid identification of the patient and his agent, as well as the legal certification materials and power of attorney of the agency relationship between the agent and the patient;

(3) If the applicant is the legal heir of the deceased patient, it shall provide the death certificate of the deceased patient, the valid identity certificate of the deceased patient's legal heir, and the legal certificate of the relationship between the deceased patient and the legal heir;

(4) If the applicant is the agent of the legal heir of the deceased patient, it shall provide the death certificate of the patient, the valid identification certificate of the legal heir of the deceased patient and his agent, the legal certificate of the relationship between the deceased patient and the legal heir, the legal certificate of the agency relationship between the agent and the legal heir and the power of attorney.

Article 19 Medical institutions can copy the temperature list, doctor's advice, hospitalization records (admission records), operation consent, anesthesia consent, anesthesia records, operation records, nursing records of critically ill patients, discharge records, informed consent for blood transfusion treatment, consent for special examination (special treatment), pathological reports, inspection reports and other auxiliary examination reports for applicants.