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改进病案复印审批程序的探索和实践

The Exploration and Practice of Improving Examination and Approval Procedure of Medical Records Duplication

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【作者】 李书梅; 徐小莉; 宋琳; 何宏涛; 温转;

【Author】 Li Shumei,Xu Xiaoli,Song Lin,He Hongtao,Wen Zhuan,No.4 Hospital of Hebei Medical Hospital,Hejiazhuang 050011,Hebei Province,China

【机构】 河北医科大学第四医院;

【摘要】 目的改进病案复印审批程序,提升患者对病案复印的满意度。方法设计病历复印申请书(分上下两联),由临床科室填写,上联随病历回病案科,下联交患者用于取病历复印件,实现临床科室和病案管理人员双重审批,减少复印中间环节。结果改进后的审批流程提高了临床医护人员对病历书写的重视度,病历归档及时,减少了医患纠纷。结论病案复印审批程序的改进得到临床医师和患者的认可,更加有利于病案管理。

【Abstract】 Objectives improving examination and approval procedure for medical records duplication in order to increase satisfaction degree from patients.Methods To design an application form of medical records duplication(with 2 same pages),filling by clinical departments,one page go with the medical record to medical records office,the other one are given to patients for their getting duplication of medical records,which can achieve double examination and approval between clinical departments and manager from medical records and intermediate link of duplicate.Results The examination and approval procedure after improving not only enhance value degree of clinical medical staffs to medical records writing and timely filing of medical records,but also reduce doctor-patient tangle.Conclusions The improvement of examination and approval procedure of medical records is approved by clinical doctors and patients that are more beneficial to medical records management.

  • 【文献出处】 中国病案 ,Chinese Medical Record , 编辑部邮箱 ,2011年07期
  • 【分类号】R197.3
  • 【被引频次】2
  • 【下载频次】69
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