Requirements and process of medical record archiving in Wuhan Aier Eye Hospital
Wuhan Aier Eye Hospital is a modern hospital focusing on the diagnosis and treatment of eye diseases. In the process of hospital operation, the archiving of medical records is a very important link. This article will describe the requirements and process of medical record archiving.
Medical record archiving requirements
1. Integrity requirements: the medical record filing requirements include the patient's basic information, chief complaint, diagnosis results, treatment plans and specific medical orders. Each medical record shall record the whole process of the patient's visit, as well as the follow-up and reexamination.
2. Normative requirements: The writing of medical records should be standardized, including accurate words, clear structure, concise words and fluent language. When writing medical records, doctors should pay attention to the standardization of medical terms and professional terms to ensure the accuracy of medical records.
3. Confidentiality requirements: medical records involve the personal privacy of patients. The hospital must strictly comply with relevant laws and regulations when archiving and using medical records to ensure that patients' privacy is not disclosed.
Medical record archiving process
1. Information entry: After the patient arrives at the hospital, the front desk will create an electronic medical record file for the patient, including the patient's basic personal information, contact information, etc. Enter the patient information into the electronic medical record system and generate a unique medical record number.
2. The doctor fills in the medical record: after interviewing the patient, the doctor makes diagnosis and treatment plan according to the patient's condition, and fills in the corresponding medical record in the electronic medical record system. Doctors should accurately record the patient's medical history, symptoms, signs, examination results and other information.
3. Review and signature: After filling in the medical record, the doctor will submit it to the attending physician for review and sign for confirmation. The attending physician is responsible for checking the accuracy and completeness of the medical record content, and reviewing the doctor's diagnosis and treatment plan and orders.
4. Filing and archiving: After the audit is completed, the medical record will be archived in the hospital's electronic medical record system. The hospital should establish a sound medical record archiving management system to ensure the security and traceability of archiving. Archive the medical records according to the specified time requirements, and regularly back up the medical record data for future needs.
Summary
Medical record archiving is an indispensable part of the work of Wuhan Aier Eye Hospital. The integrity, standardization and confidentiality of medical record archiving requirements ensure that doctors can accurately record and use medical record information during diagnosis and treatment. The information entry, doctor filling, review and signature, archiving and archiving of the medical record archiving process ensure the correctness and reliability of the medical record. The hospital will continue to strengthen the management and standardization of medical record archiving, improve the quality of medical service, and better serve patients.
