Medical record archiving management rules

Medical records are important medical documents. They are the original records of the occurrence, development, outcome and entire treatment process of a patient's disease. The following are the medical record archiving management rules, welcome to read!

Medical record archiving management rules one

1. Discharge medical record archiving management regulations

(1) All medical records are accompanied by After the patient is discharged from the hospital, he or she is sent to the inpatient department for discharge procedures.

(2) If some medical records, pathology reports and laboratory examination reports are still not reported when filing, the medical records should be filed first and sent to the medical record room to complete the medical records after the results are reported.

(3) The medical records of deceased patients are also filed according to the above requirements. To discuss death cases, the department must re-borrow the medical records from the medical record room, and the borrowing shall comply with the relevant provisions of the "Medical Records Borrowing System".

(4) The staff of the medical record room will go to the hospitalization area at any time to collect medical records and complete the registration and signature procedures.

(5) Each ward will complete the medical records before the patient is discharged, and the ward staff will send them to the hospitalization office to fill in the handover record, which will be signed and approved by both parties.

(6) All archived medical records are required to be signed by the resident physician, attending physician and quality control physician before filing. Those who are unable to complete the process will be treated as failure to file medical records in a timely manner.

(7) Medical records that fail to be filed on time will be included in the overall medical record quality evaluation, reported to the whole hospital, and corresponding bonuses and salary penalties will be imposed.

(8) If a copy of the medical record is lost, the relevant responsible person will be deducted 1,000 yuan. If a medical dispute occurs due to the loss of the medical record, the responsible person shall bear other responsibilities caused by the loss of the medical record in addition to financial penalties.

2. Medical record borrowing regulations

(1) Medical records are special archives of the hospital and implement a closed management model.

(2) Patients have no right to borrow or carry their own medical records.

(3) Other medical institutions have no right to borrow hospital medical records.

(4) All loaned medical records must be returned within 3 days. If they need to be used again, the renewal procedure should be completed. Among them, medical records accessed by the medical, quality control, medical insurance, and rural cooperative cooperative offices should be returned on the same day after the inspection is completed.

(6) Medical records are managed in a closed manner, and limited borrowing is carried out in the following four situations according to special requirements. In principle, only archived medical records can be borrowed, and unarchived medical records are not allowed to be lent.

1. When the treating physician of the hospital accesses the medical records of readmitted patients, the borrower must be the treating physician. If he is a non-treating physician or an intern (training) physician, he must have the signature of the treating physician. The IOU must be signed by both parties before it can be borrowed.

2. When conducting clinical teaching or discussing death (difficult) cases, the borrower must be a physician in the department where the patient died (critical or difficult). If he is an intern or a training physician, a double signature system must be implemented. Borrow.

3. If you need to borrow medical records under special circumstances, you must have a borrowing application stamped by the medical office.

4. The borrowed medical records are complete and must be returned within 3 days. Otherwise, they will be treated as unfiled medical records and will be included in the unfiled scope and will be notified and corresponding bonuses and salary penalties will be imposed (for more than 7 days, the person concerned will be deducted from 100 yuan to 100 yuan per day)

7. Except for the four circumstances stipulated in Article 6, no medical records shall be lent to the medical record room, including the following circumstances:

1. Nurses from the Nursing Department and each ward. (Long) Conduct quality control inspections on nursing records

2. Review relevant information in the Pharmacy Department

3. Inspect medical insurance, rural cooperative medical care, and quality control (as much as possible. (Conducted in the medical record room)

4. All medical record copying work

5. Postgraduate research projects require the signature of the teaching physician (official employee of the hospital).

Applications for review of words are only allowed in the medical record room, and the reviewer must be a person participating in the project. No more than 20 copies may be reviewed at a time.

6. When doctors of our hospital need to review medical records while engaged in scientific research projects. , only allowed in the medical records room, and only the medical records of the patients who have been treated can be viewed.

8. Other circumstances not specified

(8) Borrowing. Medical records should be properly kept, and it is strictly prohibited to alter, dismantle, lose, lend to others, take away from the hospital, copy or copy. If such a situation occurs, the parties involved will be held accountable according to the law after verification and will be punished accordingly

< p> These regulations shall be implemented from the date of issuance.

Medical Records Archiving Management Detailed Rules 2

Chapter 1 General Provisions

Article 1 In order to strengthen the management of medical records, these regulations are formulated.

Article 2 Physicians shall write and sign medical records in strict accordance with the requirements of the "Basic Standards for Writing Medical Records" issued by the Ministry of Health and the State Administration of Traditional Chinese Medicine.

Article 3 The resident physician is responsible for writing medical records, and the attending physician is responsible for reviewing the medical records. Special circumstances shall be written by the attending physician or above in the department. Intern doctors cannot write admission records on behalf of resident doctors. The disease course records written by them and the medical records written by visiting doctors and graduate students must be reviewed and signed by the superior doctors of the hospital. The department director is the person responsible for medical record management. The Medical Office is responsible for the supervision and inspection of medical record management.

Chapter 2 Basic Requirements for Medical Record Inspection and Management

Article 4 Fill out the "Beijing Hospital Outpatient Medical Record Inspection Form" on time. The directors of each department should check at least 10 undergraduate medical records every quarter to understand the writing status of medical records and strengthen the management of medical record writing.

Article 5: The Medical Office organizes experts to inspect each discharged medical record, establishes technical files for professionals, and records the writing and inspection of medical records as the basis for selecting advanced and professional titles.

Article 6 Key points of medical record inspection

(1) Whether the writing in the medical record is true and clear, and whether the expression is accurate.

(2) Whether each record is completed within the specified time limit

1. Completion time of each record

The admission record shall be completed within 24 hours after the patient is admitted.

The first course of illness recording is completed within 8 hours after the patient is admitted to the hospital.

Discharge records are completed within 24 hours after the patient is discharged.

Death recording is completed within 24 hours of the patient’s death.

The surgical records will be completed by the surgeon within 24 hours after the operation.

The rescue record shall be accurately recorded and noted within 6 hours after the end of the rescue.

2. Disease course recording time

Critically ill patients should record changes in their condition at any time, at least once a day, and the recording time should be down to the minute.

For seriously ill patients, the course of the disease should be recorded at least once every 2 days.

For patients whose condition is stable, the course of the disease should be recorded at least once every 3 days.

The course of the disease must be recorded before surgery and the day before discharge.

The surgical patient’s course record should reflect the surgeon’s view of the patient before surgery.

The anesthetist will review the patient’s records before and after the operation.

The course of the disease should be recorded at least once a day for the first three days after surgery.

If the patient is hospitalized for more than one month, a summary of the condition must be done once a month.

When the physician treating a patient changes, a handover and succession record must be written.

3 Ward rounds records of superior physicians

Patients must have ward rounds and preliminary diagnosis and treatment opinions from the attending physician or above within 48 hours of admission.

Patients must have ward rounds and preliminary diagnosis and treatment opinions from a physician above the deputy director (inclusive) within 72 hours of admission.

Difficult patients must have records of ward rounds and case discussions by a physician above the deputy director level.

Critically ill patients must have daily ward rounds records from superior physicians.

Seriously ill patients have records of ward rounds by a superior physician at least once every three days.

Patients with stable conditions must have ward rounds records from superior physicians within 5 days.

4. Informed consent must be obtained for surgeries, special examinations and treatments.

Article 7: All clinical departments, department directors, and medical offices must carefully inspect key medical records and inspect the quality of terminal medical records. Department directors should strengthen spot checks on key medical records. Before the medical records are returned to the medical record room, the department medical record committee member or the attending physician is responsible for a comprehensive examination of the medical records and filling out a checklist. The checklist is completed together with the discharge medical record and returned to the medical records room. The medical office organizes experts to evaluate the quality of medical records.

Article 8 The Medical Office shall report the management status of medical records of each department within a certain range every quarter.

Chapter 3 Rewards and Punishments for Medical Record Examination Results

Article 9: A bonus of RMB 200 will be deducted for each Grade B medical record; a bonus of RMB 800 will be deducted for each Grade C medical record. The department director shall impose individual penalties based on the degree of responsibility of the physician involved in the defects in the medical record.

Article 10: Those who have one Class C medical record or three Class B medical records during the year will also be subject to the following treatment

(1) Attending physician or above: the hospital will delay the hiring of newly promoted personnel One year for a technical title.

(2) Resident physicians: Delayed for one year to enter the next stage of training.

(3) Graduate students: disqualified from staying in the hospital.

(4) Visiting students: The qualifications of visiting students will be cancelled, and they will be changed to study tours. No completion certificate will be issued.

(5) The director of the department where the person concerned is located shall be notified to the whole hospital.

Article 11: Other defects in medical records will be included in the one-thousand-copy management system to deduct points.

Article 12: Score on the final quality inspection of medical records

The top three scorers will be awarded 2,000 yuan for the doctor in the treatment group and 1,000 yuan for the department. For those who place in the bottom 3 points, a bonus of RMB 2,000 will be deducted for each subject.

Article 13: Departments with Class C medical records or 3% Class B medical records with 3% of *** in the whole year cannot participate in the selection of advanced departments and advanced party branches.

Chapter 4 Supplementary Provisions

Article 14 Definition of Class B Medical Records

Those with one of the following major quality defects are Class B medical records

< p> (1) The medical information on the home page is not filled in.

(2) Underreporting of infectious diseases.

(3) The first disease course record is missing or the diagnostic basis, differential diagnosis and diagnosis and treatment plan of the main diagnosis are missing in the first disease course record.

(4) Lack of diagnosis and treatment plan (or surgical plan) signed and confirmed by the attending physician or above.

(5) The absence of ward rounds records of department directors or deputy chief physicians or above for critically ill patients during their hospitalization.

(6) Lack of surgical records.

(7) Death cases lack rescue records before death.

(8) Lack of discharge records or death records.

(9) New surgeries (techniques) and major surgeries carried out lack the signature of the department director or authorized superior physician.

(10) Lack of consent form for invasive examination (treatment), surgery or the signature of the patient (client).

(11) Lack of auxiliary examination report sheets that play a decisive role in diagnosis and treatment.

(12) There is evidence to prove that the medical record recording was a principled error caused by copying behavior.

(13) The medical record is incomplete due to the missing entire page of the medical record.

(14) There are obvious alterations.

(15) Imitate others or sign on behalf of others in medical records.

Article 15 Definition of Class C medical records. There is a lack of admission record in the terminal medical record (written by an intern will be deemed as a lack of admission record) or there are three or more defects listed in Article 14 of these regulations.

Article 16: The examination of key links in medical records refers to the examination of key links in medical records while the patient is still hospitalized.

Article 17 The quality inspection of terminal medical records refers to a comprehensive inspection before the medical records are returned to the medical record room for archiving.

Article 18 These regulations have been revised, adopted and implemented since October 8, 20xx.

Article 19 The Medical Department is responsible for the interpretation of these regulations.

Medical Records Archiving Management Rules 3

1. Our hospital temporarily implements a 72-hour archiving system for medical records. That is, medical records will be placed in the medical record room within 72 hours after the patient is discharged.

2. The time-limited evaluation method for medical record archiving is a comprehensive evaluation based on the monthly "Monthly Report on Medical Record Archiving Status" produced by the medical record room. Evaluation indicators include: 24-hour filing rate, 48-hour filing rate, 72-hour filing rate, etc.

3. Archive date calculation formula: (Take 72 hours of archive time as an example)

1. Calculation of medical record archive date for discharges on working days: discharge date on the home page of the medical record + 72 hours.

2. Calculation of the filing date of medical records for patients discharged on holidays: discharge date + number of holidays after the discharge date + 72 hours.

4. The filing of medical records adopts a combination of collection and delivery.

1. Special personnel from the medical record room will go to the ward regularly to collect discharge medical records and have them signed by both parties. After the medical record is collected by a dedicated person in the medical record room, the hospitalization number will be entered into the computer for registration on the same day.

2. The medical records returned to the ward will be sent to the medical record room by the department’s chief resident or the department’s chief resident for electronic signature and filing.

After signing, the medical record room prints the handover form, the recipient and the sender sign, and the handover form is kept by the hospital chief.

3. The medical record room is responsible for collecting medical records on a regular basis. After receiving the call to collect medical records, 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 archived medical records, if the staff of the medical record office find that there are missing pages, missing items, incomplete filling, serious stains and damage, etc., they have the right to reject them and have them completed by the department and sent to them on the same day. Medical record room.

5. The treatment team is responsible for quality management before medical records are filed, focusing on the following aspects:

1. Completeness and order. You should first check and ensure that the home page of the medical record, discharge summary, case discussion records, admission records, disease course records, consent forms, surgical documents, consultation orders, nursing documents, special report attachment sheets, imaging examination reports, laboratory test reports, and medical orders The 15 basic items of the medical record, including the sheet, body temperature sheet, and infection form, must be complete and must not be missing, and they must be arranged in accordance with the basic standards for writing this medical record.

2. Check the completeness of doctor-patient communication and various consent forms. Before filing the medical records, the department physicians will check whether the various notification and consent forms are complete based on the characteristics of the department and the content of this diagnosis and treatment, and any missing ones should be completed in a timely manner.

3. Ensure that the inspection and laboratory reports are complete. Before filing medical records, doctors should check various examination and laboratory reports and medical orders one by one. Departments should set up fixed locations for classified storage of reports that are not classified into medical records.

4. Ensure the completeness of nursing records. Before filing medical records, the nursing department should conduct complete quality control on nursing assessments, notification letters, nursing record sheets, monitoring sheets, temperature sheets and other documents, and sort them according to recording time.

6. If the medical record has reached the filing time, but there are inspections and tests but no report form has been issued, file the medical record first and write the name of the missing report form with a pencil in the upper right corner of the cover of the medical record. After the report form comes out, it will be sent to the medical record room on the same day.

7. When the department’s late-filed examination and laboratory reports are sent to the medical records room, if the medical records are not bound, the person who sent them will put (pasted) them directly into the medical records. If the medical record has been bound, in principle, the medical record should not be opened; the department must write a report explaining the reason for the late return, which should be signed by the department director and submitted to the Medical Office for approval;

After the Medical Office approves, it will be submitted to the Medical Records Office to fill in the medical record. The inspection and laboratory report forms submitted to the medical record room must be handed over and registered.

8. If the staff of the medical record room find any missing items during the process of sorting out medical records, they should promptly notify the department’s chief resident. The hospital manager will promptly complete the defective medical records on the same day after answering the call. The medical record room will register the missing items.

9. Before the medical record is filed, if the patient needs to copy the medical record, the following two conditions must be met, otherwise the medical record room will not make the copy: 1. The copyer’s ID is complete; 2. The medical record information meets the quality requirements for archived medical records.

For those who meet the requirements for copying, the undergraduate doctor will accompany the patient with the medical record to the medical record room for copying and then bring it back to the department. The department is not allowed to hand over medical records to patients, nor is it allowed to take medical records outside the hospital for copying; otherwise, the department will be responsible for all consequences.

10. Before filing medical records, when it is necessary to seal medical records due to medical disputes, the contents of the medical records should be completed first, and then sealed, and the sealed files should be handed over to the medical record room for preservation. After the medical records are unsealed, the department should organize the medical records and then archive them.