摘要
现行的相关法律法规对指导病案封存和开封方法没有详细指引,实际应用中常有漏洞容易引发额外医疗纠纷。目前我们的病案封存工作中仍然存在对封存申请人审核不严、封存申请手续不齐、封袋的书写不完整、封存好的病案由何部门保管等许多问题,需要医疗机构加强对住院病案封存的规范化及合法化管理。本文通过对照相关法律法规,探讨病案封存和开封的方法,保护医患双方的合法权益,并结合实际工作制定具体方案:(1)确定及审核封存和开封病案的合法申请人;(2)病案封存的内容及可以复印的内容;(3)封袋的书写内容;(4)封存病案的管理;(5)封存病案的启封时间和方法。
Current related rules and regulations do not have details instruction for medical records seal and unseal methods which easily lead to additional medical tangle in actual application.At present,work of medical records seal still exist problems like non-strict examination to seal applicant,incomplete seal application procedure,incomplete writing of seal packet,sealed medical records guarded by what department,which need to strengthen standardization management for hospitalization medical records seal.Through comparing related laws and regulations,this paper discusses the methods of seal and unseal of medical records for protecting legal interests between doctor and patient.It makes out concrete plans combing with actual work as followings：（1） confirm and examination of legal application for medical records seal and unseal;（2） the content of seal and content that can be duplicated;（3） writing content of seal packet;（4） the management of medical records seal：（5） unseal time and methods of medical records seal.
出处
《中国病案》
2012年第1期10-11,共2页
Chinese Medical Record
关键词
病案
封存
Medical records
Seal
