Traditional Culture Encyclopedia - Traditional festivals - When was it stipulated that medical records should be kept for 30 years?
When was it stipulated that medical records should be kept for 30 years?
Medical record file, also referred to as medical record, refers to the sum of words, symbols, charts, images, slices and other materials formed by medical staff in the process of diagnosis and treatment of patients' diseases. It objectively, completely and continuously records the changes of patients' condition and the process of diagnosis and treatment. It is the basic data of clinical scientific diagnosis and treatment and an important basis for safeguarding the rights and interests of doctors and patients.
1. How many years is the retention period of medical records?
According to the law, medical records are divided into three types:
1, hospital medical records, hospital custody time shall not be less than 30 years, lost or damaged by the hospital;
2, the establishment of outpatient medical records in the hospital, hospital custody time shall not be less than 15 years;
3. The outpatient medical records kept by patients, including laboratory tests, checklists and registered ticket stubs, must be properly kept by these patients.
Second, does the hospital have the obligation to keep patients' cases?
The patient's medical records are kept by the hospital.
According to Chinese laws, patients have the right to copy or duplicate their outpatient medical records, inpatient medical records, temperature sheets, doctor's orders, laboratory tests (inspection reports), medical imaging examination data, special examination consent, operation consent, operation and anesthesia records, pathological data, nursing records and other medical records specified by the health administrative department of the State Council.
If a patient requests to copy or duplicate medical records in accordance with the provisions of the preceding paragraph, the medical institution shall provide copying or duplicating services, and affix the certification mark on the copied or duplicated medical records. When copying or duplicating medical records, patients should be present.
The management of hospital medical records has legal provisions, which should be kept in the hospital and provide access services.
Legal basis:
Regulations on Medical Records Management of Medical Institutions (20 13 Edition)
Twenty-eighth medical institutions can use microfilm technology that meets the requirements of file management to process and save paper medical records.
Twenty-ninth outpatient (emergency) medical records shall be kept by medical institutions for not less than 15 years from the date of the patient's last visit; The preservation time of in-patient medical records is not less than 30 years from the date of the patient's last hospitalization and discharge.
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