醫(yī)院病歷管理制度

1、醫(yī)院病歷管理制度 一、門(急)診病歷必須有連續(xù)的頁碼，由病員自行保管。急診留觀期間，急診留觀病歷由急診科負責保管。 二、病員住院期間，其住院病歷由所在病區(qū)負責整理、統(tǒng)一保管。病區(qū)應將收到的住院病員的檢查報告等結果于24小時內(nèi)歸入住院病歷。病員出院后的住院病歷由病案室負責保管，年限不少于30年。 三、急診留觀病歷和住院病歷分別編號保存。入院病歷、入院記錄及所有主觀病歷應標注連續(xù)的頁碼。 四、科室必須嚴格保管病歷，嚴禁病員翻閱病歷。嚴禁隱匿、銷毀、搶奪、竊取病歷。 五、病歷在科室、護保中心、住院處（醫(yī)保辦）和病案室的流通過程中，應嚴格簽收制度。六、住院病歷、急診留觀病歷因醫(yī)療活動或復印、復制等需要

2、帶離病區(qū)時，應由科室指定專人負責攜帶和保管。七、病歷借閱：1、除涉及病員實施醫(yī)療活動的醫(yī)務人員及醫(yī)教部相關人員外，其它任何機構和個人不得擅自借閱病員的住院病歷。2、本院正式醫(yī)務人員（含有處方權的研究生）一次借閱不得超過20份；合同醫(yī)生、進修生須經(jīng)上級醫(yī)生同意后方可借閱，一次不得超過2份。借閱病歷應盡快歸還，借閱最長時限不超過5天。3、借閱者須持正式印章前往病案室借閱，不得他人代借、轉借。4、借閱者應愛護病案，確保病案的完整。丟失病案者將視情給予經(jīng)濟和行政處罰。5、本院醫(yī)師調(diào)離，轉業(yè)或其他原因離開本院，歸還全部所借病案后方能辦理離院手續(xù)。八、病歷復?。ㄔ卺t(yī)務人員按規(guī)定時限完成病歷后予以提供）：1

3、、對下列人員和機構復印或復制病歷資料的申請應當受理：（1）病員本人或其代理人。（2）死亡病員近親屬或其代理人。（3）保險機構。2、受理申請時，申請人按照要求應提供有關證明材料：（1）申請人為病員本人的，應當提供其有效身份證明。（2）申請人為病員代理人的，應當提供病員及其代理人的有效身份證明及代理關系的法定證明材料。（3）申請人為死亡病員近親屬的，應當提供病員死亡證明及其近親屬的有效身份證明及近親屬的法定證明材料。（4）申請人為死亡病員近親屬代理人的，應當提供病員死亡證明、近親屬及其代理人的有效身份證明、近親屬關系的法定證明材料、代理關系的法定證明材料。（5）申請人為保險機構的，應當提供保險合同

4、復印件，承辦人員的有效身份證明，病員本人或者其代理人同意的法定證明材料；病員死亡的，應當提供近親屬或者其代理人同意的法定證明材料。合同或者法律另有規(guī)定的除外。3、公安、司法機關因辦理案件，需要查閱、復印或者復制病歷資料的，由公安、司法機關向醫(yī)教部出具采集證明的法定證明及執(zhí)行公務人員的有效身份證明后方可給予協(xié)助辦理。4、可以為申請人復印或者復制的病歷資料包括：住院病歷的入院記錄、體溫單、醫(yī)囑單、化驗單（檢驗報告）、醫(yī)學影像檢查資料、特殊檢查（治療）同意書、手術同意書、手術及麻醉記錄單、病理報告、護理記錄、出院記錄。九、發(fā)生醫(yī)療問題爭議時，由醫(yī)教部醫(yī)療科專職助理員在病員或其有關人員在場的情況下封存

5、病歷。封存的病歷由病案室負責保管。封存的病歷可以是復印件。gz7r4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgshls50clmtwn60eo8wgqv7xav2ohum32wgeauwydiawgmer4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgz7r4i30ka1dkagtgkqcwa3p tgz7r4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgshls50clmtwn60eo8wgqv7xav2ohum32wgeauwydi

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