医院医疗文件管理制度.doc

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1、医院医疗文件管理制度 一、由病房护士长负责医疗文件的管理,护士长不在时,由办公室护士负责管理,各班人员均需按管理要求执行。 二、住院期间的医疗文件要求存放有序,病历中各种表格均应排列整齐,不得撕毁、涂改或丢失,病历用后必须归还原处。 三、病人不得自行携带病历出科室,外出会诊或转院时带病历摘要。 四、病人出院或死亡后,病历次序按规定排列,一周内送病案室保管待添加的隐藏文字内容3 五、病房交接班记录,必须按要求书写,并妥善保管一年,以备查阅。 六、病房医嘱本的保存期限,按各医院规定,一般不少于一年。 七、护士长必须定期检查体温单、护理记录单等的书写质量。29C91AFE4CED1B6C8795AD

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