The medical record copying system refers to the system that medical institutions set up special departments or full-time staff to provide patients with medical records for consultation, copying and sealing, which is implemented by the Ministry of Health and state administration of traditional chinese medicine according to the Regulations on the Management of Medical Records. The following are the regulations on the management of medical record copying that I have compiled for you. I hope they are useful to you!
Regulations on the Management of Medical Records Copying
1. Legal persons for medical records copying: Medical records belong to patients' privacy. According to relevant laws and regulations, the following four kinds of legal persons are legal persons for medical records copying, and other persons have no right to copy patients' medical records:
1. Patients themselves or their entrusted agents;
2. Close relatives of deceased patients or their agents
3. Insurance institutions;
4. Public security and legal departments.
2. Copying time of in-patient medical records: there are two categories:
1. Filing medical records: patients need to be reimbursed (discharge records must be stamped with official seals) and other materials, so please go to the Medical Records Department for copying two weeks after discharge.
2. In-hospital medical records: only the examination and laboratory results are provided during hospitalization, and the medical records are sent to the Medical Records Department for copying by the staff assigned by the department.
3. The medical records of the inpatients must be copied in the Medical Records Department, and no one may copy the medical records in any way.
IV. Relevant supporting materials must be provided to the hospital for copying medical records:
1. 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 identity certificate of the patient and his agent, the legal proof of the agency relationship between the applicant and the patient and the power of attorney;
3. If the applicant is a close relative of the deceased patient, it shall provide the death certificate of the patient and the valid identification certificate of his close relatives, and the legal proof that the applicant is a close relative of the deceased patient;
4. If the applicant is the agent of the deceased patient's close relatives, it shall provide the patient's death certificate, the valid identification certificate of the deceased patient's close relatives and their agents, the legal proof of the relationship between the deceased patient and his close relatives, the legal proof of the applicant's agency relationship with the deceased patient's close relatives and the power of attorney;
5. To apply for copying minor medical records, you need to hold the guardian's ID card (original), the patient's household registration book or the original birth certificate. If the agent is a third party (that is, a non-parent party), the agent should hold the patient's ID card and the original ID card of the entrusted agent, the patient's signature or fingerprint the power of attorney when applying for copying the medical record. Among them, the newborn (within 3 days of birth) needs to provide his own ID card (original) if he needs his mother to handle it, and his parents' ID cards (original) if his father acts as an agent.
6. For the staff of an insurance institution, the applicant must provide the insurance contract, the ID card of the staff of the insurance company, and the power of attorney signed by the patient or his agent. The underwriting department of an insurance company shall provide the ID card of the undertaker, the letter of introduction from the insurance company and the insurance contract to check the previous hospitalization history. If the patient dies, it shall provide a copy of the insurance contract, the valid identity certificate of the undertaker, and the legal certification materials agreed by the close relatives of the deceased patient or his agent. Unless otherwise stipulated in the contract or law.
7. If the applicant is performing official duties for the public security, procuratorate, court, etc., to consult or copy medical records, he/she must produce proof materials, his/her work certificates and identity documents. There must be two or more people who have filed a case, and they should go to the medical department for filing and go through relevant formalities first, and the medical department will issue a certificate to consult or copy the medical records.
V. Contents of medical records copying:
Medical institutions only provide the applicants with the copied medical records: hospitalization records (i.e. admission records), temperature sheets, doctor's orders, laboratory tests (inspection reports), medical imaging examination data, special examination (treatment) consent, operation consent, operation and anesthesia records, pathological reports, nursing records and discharge records.
VI. In the event of a medical accident dispute, the department or full-time (part-time) staff in charge of medical service quality monitoring of the medical institution shall seal up the discussion records of death cases, difficult cases, superior doctors' rounds, consultation opinions and course records in the presence of patients or their agents. The sealed medical records shall be kept by the department or full-time (part-time) staff of the medical institution responsible for monitoring the quality of medical services. The sealed medical record can be a copy.
seven, according to the regulations, there is a certain fee for copying medical records. A4 paper .5 yuan/sheet.
VIII: Copy time: 8: -12: from Monday to Friday; 14: -17:
Sample power of attorney for copying medical records
Client (patient himself):
Valid ID number:
Gender and age Tel: Trustee:
Valid ID number: Gender and age Tel: Relationship with patients:
□ Spouse □ Friends □ Other □ Children □ I solemnly entrust my agent to copy my hospital medical records and sign them on my behalf. The signature of the entrusted person is regarded as my signature. After the client signs the consent form, the consequences will be borne by the patient himself. Photocopying purposes:
□ Disability appraisal □ Medical insurance reimbursement □ Re-treatment □ Judicial purposes □ Others:
The time limit for this authorization is: from the signing date to the year, month, day, patient's signature:
Trustee's signature: (handprint) year, month, day, month, day (with
copies of both parties' ID cards and relationship certificates) # # # # #
Procedure and seal-up of medical records
1. The right subject of copying medical records:
(1) the patient himself or his agent;
(2) close relatives of deceased patients or their agents;
(3) insurance institutions;
(4) Full-time staff of public security and judicial organs needed for handling cases. In addition, no one else has the right to copy the patient's medical record.
2. Specific steps for copying medical records:
(1) When the applicant applies, he shall submit relevant supporting materials. If the patient and his agent apply, he shall provide his valid identity certificate and relationship certificate; If the applicant is an insurance institution, it shall provide a copy of the insurance contract.
(2) review the application and provide a copy. After accepting the application, the medical staff shall provide it after completing the medical records within the prescribed time limit. After a medical institution accepts an application for copying or duplicating medical records, the department responsible for monitoring the quality of medical services or the department or ward responsible for keeping the medical records of the outpatient (emergency) clinic will send the medical records that need to be copied or duplicated to the designated place within the specified time limit, and copy or duplicate them in the presence of the applicant.
(3) The first page of the copied medical record and the important pathological contents are directly stamped with the confirmation stamp, and other medical records can be stamped with the riding seal.
in case of medical malpractice dispute, the department or full-time staff in charge of medical service quality monitoring of medical institutions should seal the discussion records of death cases, difficult cases, superior doctors' rounds, consultation opinions and course records in the presence of patients or their agents. The sealed medical records shall be kept by the department or full-time staff of the medical institution responsible for monitoring the quality of medical services. The sealed medical record can be a copy.