CAJ | 학술논문

目的：探讨封存病案的方式及流程，以达到依法、按流程封存病案的目的。方法对我院发生的关于医疗纠纷所封存的病案进行资料采集，讨论我院封存病案的方案是否合理。在查阅相关法律、法规，文献资料，结合实际工作中对病案封存的认识，讨论封存病案的最佳方式及流程。结果医疗纠纷率随着时间的推移呈逐年增长趋势，而其造成的封存病案数量也随之增加。对纠纷病案封存要高度重视，改进方式优化流程，从而更好地为患者服务并保护医疗主体。结论《医疗机构病历管理规定》和《医疗事故处理条例》没有对封存病案有一个明确的规定，所以病案封存工作中依然存在许多问题，需要医疗机构加强封存病案管理的规范化、合理化、合法化。
목적：탐토봉존병안적방식급류정，이체도의법、안류정봉존병안적목적。방법대아원발생적관우의료규분소봉존적병안진행자료채집，토론아원봉존병안적방안시부합리。재사열상관법률、법규，문헌자료，결합실제공작중대병안봉존적인식，토론봉존병안적최가방식급류정。결과의료규분솔수착시간적추이정축년증장추세，이기조성적봉존병안수량야수지증가。대규분병안봉존요고도중시，개진방식우화류정，종이경호지위환자복무병보호의료주체。결론《의료궤구병력관리규정》화《의료사고처리조례》몰유대봉존병안유일개명학적규정，소이병안봉존공작중의연존재허다문제，수요의료궤구가강봉존병안관리적규범화、합이화、합법화。
Objective To investigate the manner and process of archiving medical records,hospital archive process optimization in order to achieve the law,according to the process to complete medical record complete archive.Methods According to our hospital on medical disputes occurred archived medical records for data collection,to discuss my hospital medical record archiving solutions are reasonable. After reviewing the relevant laws,regulations,documentation,combined with practical knowledge of the Task Force medical record storage,medical record good way discussion archives and processes.Results dispute medical record rate as time goes on increasing year by year,and because of disputes caused by the number of medical records storage also increases,so the dispute archived medical record should attach great importance to improve the way to optimize processes and achieve better services for patients and well protected medical subject. Conclusion "medical institution medical records management regulations" and "Medical Malpractice" did not have a clear medical record storage requirements,medical records storage work so many problems still exist,requiring medical institutions to strengthen the standardization of the management of medical records storage,rationalizing,legalization.