What Is a Medical Record Review?

A case history is a record of medical personnel's medical activities, such as the occurrence, development, and outcome of a patient's disease, and inspection, diagnosis, and treatment. It is also the patient's medical health file that is summarized, sorted, and comprehensively analyzed based on the collected data. Medical records are not only a summary of clinical practice work, but also a legal basis for exploring the laws of diseases and handling medical disputes, and are a valuable asset of the country. Medical records play an important role in medical treatment, prevention, teaching, scientific research, and hospital management.

[bìng lì]

Case history

1. "

   Medical history, also called medical history,

   The "earliest medical records" in the world and in China:

   1. As early as the 6th century BC, since the east coast of the Gulf of Agolis in ancient Greece

   Medical records are not only a summary of clinical practice work, but also a legal basis for exploring the laws of diseases and handling medical disputes, and are a valuable asset of the country. For this reason, medical personnel must be practical, serious, scientific and rigorous in their writing of medical records. Medical records play an important role in medical treatment, prevention, teaching, scientific research, and hospital management.

   1. Medical treatment: Medical records are not only the information for determining diagnosis, treatment, and implementation of preventive measures, but also the basis for evaluating the level of disease diagnosis and treatment of medical personnel, and also an important reference for diagnosis and treatment of patients when they are sick again. By reviewing clinical records, you can learn from them, improve your work, and improve

   Can be divided into:

   1. Outpatient (emergency) medical records

   • Medical Record Home (Handbook Cover)

   • Medical record

   • Test sheet (inspection report)

   • Medical Imaging Information

   2. Hospital records

   • Inpatient Cases Home

   • Admission record

   • Course record

   • Informed consent

   • Doctor's order

   • prescription

   • Nursing papers

   • Inspection report

   Currently the main implementation is the "Basic Norms for Writing Medical Records" (Wei Yi Zheng Fa [2010] No. 11)

   The first medical record refers to the words and symbols formed by medical personnel during the medical activity.

   Procedure for sealing medical records, if it is the patient, he should hold his valid ID

   Article 1 In order to strengthen the management of medical records of medical institutions and ensure that the medical records are objective, authentic and complete, these regulations are formulated in accordance with regulations such as the Regulations on the Management of Medical Institutions and the Regulations on the Treatment of Medical Accidents.

   Article 2 Medical records refer to the total of texts, symbols, charts, images, slices and other data formed by medical personnel during medical activities, including outpatient (emergency) medical records and hospital medical records.

   Article 3 Medical institutions shall establish a medical record management system, set up a special department or allocate full-time (part-time) personnel, and be specifically responsible for the preservation and management of medical records and medical records of the institution.

   Article 4 If an outpatient (emergency) medical record file is constructed on a medical machine, the outpatient (emergency) medical record is maintained by the medical institution; if the outpatient (emergency) medical record file is not established in the medical institution, its outpatient (emergency) diagnosis The medical records are kept by the patient. The medical records of the hospitalization are kept by the medical institution.

   Article 5 Medical institutions shall strictly manage medical records, and it is strictly forbidden for anyone to alter, falsify, hide, destroy, rob or steal medical records.

   Article 6 Except for medical personnel and medical service quality monitoring personnel who carry out medical activities on patients, no other institution or individual may inspect the patient's medical records without authorization. If medical records need to be consulted for scientific research and teaching, they should be consulted with the consent of the relevant department of the medical institution where the patient consulted.

   It should be returned immediately after reading. Do not disclose patient privacy.

   Article 7 Medical institutions shall establish a numbering system for outpatient (emergency) medical records and inpatient medical records. Outpatient (emergency) medical records and inpatient medical records shall be marked with page numbers.

   Article 8 The outpatient (emergency) medical records of patients with outpatient (emergency) medical records filed on the medical machine shall be delivered to the patient's consultation room by a person designated by the medical institution; if the patients are treated in multiple departments at the same time, the medical institution shall be appointed Served to the follow-up clinic. Within 24 hours after the end of each diagnosis and treatment activity, the patient's outpatient (emergency) medical record should be recovered.

   Article 9 Medical institutions shall return the laboratory (emergency) patient's test report (inspection report), medical imaging examination data, etc. to the entry (emergency) medical record file within 24 hours after the examination results are issued.

   Article 10 During the hospitalization of a patient, the patient's medical history shall be centralized and uniformly kept by the ward where he is located. The ward shall return to the hospital medical record within 24 hours after receiving the test results (inspection report), medical imaging examination data and other inspection results of the inpatients. The in-patient medical records shall be centrally and uniformly stored and managed by the specialized department or full-time (part-time) staff after the patients are discharged.

   Article 11 When the inpatient medical records need to be taken away from the ward due to medical activities or photocopying or reproduction, a special person designated by the ward shall be responsible for carrying and keeping it.

   Article 12 Medical institutions shall accept applications for the following persons and institutions to copy or reproduce medical records: (1) the patient himself or his agent; (2) the close relatives of the deceased patient or his agent; (3) the insurance institution.

   Article 13 Medical institutions shall be responsible for accepting applications for copying or duplicating medical record materials by the department or full-time (part-time) personnel responsible for the quality control of medical services. When accepting an application, the applicant shall be required to provide relevant certification materials in accordance with the following requirements: (1) if the applicant is the patient himself, he shall provide his valid identity certificate; (2) if the applicant is a patient agent, he shall provide the patient and his agent (3) Where the applicant is a close relative of the deceased patient, a valid certificate of identity of the patient's death and his close relatives, and a legal certification that the applicant is a close relative of the deceased patient (4) Where the applicant is an agent of a close relative of a deceased patient, a death certificate of the patient, valid identity certificate of the close relative of the deceased patient and his agent, legal proof of the relationship between the deceased patient and his close relatives, and (5) Where the applicant is an insurance institution, a copy of the insurance contract, the valid identity certificate of the contractor, and the statutory certification materials agreed by the patient or his agent; if the patient dies, he shall provide Copy of insurance contract, contractor Valid proof of identity, proof of death in patients with recent legal materials relatives or their agents agree. Except as otherwise stipulated in the contract or law.

   Article 14 If the public security and judicial organs need to consult, copy or copy the medical records for handling a case, the medical institution shall provide assistance after the public security and judicial organs have issued a statutory certificate for collecting evidence and a valid identity certificate for the public servants.

   Article 15 The medical records that medical institutions can copy or reproduce for applicants include: inpatient (emergency) medical records and inpatient records (ie admission records), temperature records, doctor's orders, laboratory tests (examination reports), Medical imaging examination data, special examination (treatment) consent, surgery consent, surgery and anesthesia record sheet, pathology report, nursing record, discharge record.

   Article 16 After a medical institution accepts an application for copying or duplicating medical records, it shall provide them after the medical staff has completed the medical records within the prescribed time limit.

   Article 17 After a medical institution accepts an application for copying or duplicating medical records, the department in charge of medical service quality monitoring or the full-time (part-time) staff shall notify the department (person) or the ward responsible for keeping the medical records of the outpatient (emergency) medical records, and shall The medical records that need to be copied or reproduced are sent to the designated place within the specified time, and are copied or reproduced in the presence of the applicant. After the photocopy or reproduction of the medical records is verified by the applicant, the medical institution shall affix a certification seal.

   Article 18 Medical institutions may charge fees for copying or copying medical records in accordance with regulations.

   Article 19 In the event of a medical accident dispute, the department or full-time (part-time) staff responsible for the quality control of medical services in a medical institution shall seal the discussion records of death cases, discussion records of difficult cases, and higher-level physicians in the presence of patients or their agents. Records of rounds of visits, consultations, records of disease course, etc. The sealed medical records shall be kept by the department or full-time (part-time) staff responsible for the quality control of medical services in medical institutions. The sealed medical records can be photocopies.

   Article 20 The retention time of outpatient (emergency) medical records shall not be less than 15 since the date of the patient's last consultation.

   year.

   Article 21 The inspection, copying or duplication of medical records shall be implemented with reference to these regulations.

   Article 22 The interpretation of these regulations is the responsibility of the Ministry of Health.

   Article 23 These regulations shall come into effect on September 1, 2002.