下面是小编为大家整理的病案管理规章制度汇编（2022年）,供大家参考。
病案管理规章制度汇编
航天七三一医院编著 2019 年
目
录
第一部分
病案管理·················································································································· 1 医院病案管理领导小组 ······································································································ 1 病案室工作制度·················································································································· 3 病案收集制度 ····················································································································· 3 病案整理制度 ····················································································································· 4 病案归档上架制度 ·············································································································· 4 病案库房防护管理制度 ······································································································ 5 病案保护及信息安全制度 ·································································································· 6 病历保管制度 ····················································································································· 7 病案室应急预案及处置流程 ······························································································ 8 病案服务管理制度、规范及程序 ···················································································· 10 病历复印制度 ··················································································································· 11 病历复印须知 ··················································································································· 13 病历复印流程图················································································································ 14 病历复印登记制度 ············································································································ 15 病案借阅归还管理制度 ···································································································· 15 病案借阅流程图················································································································ 16 保护患者隐私的规范与措施 ···························································································· 17 病历书写培训制度 ············································································································ 17 病历质量全程监控、评价、反馈制度············································································· 18 病案工作流程图················································································································ 19 第二部分
相关法律法规和规定 ···························································································· 20 医疗机构病历管理规定 ···································································································· 20 病历书写基本规范 ············································································································ 24 医疗纠纷预防和处理条例 ································································································ 32 电子病历基本规范（试行）
···························································································· 40 住院病案首页部分项目填写说明 ···················································································· 43 第三部分
病案考核细则 ········································································································ 49 病案质量考核细则（全国通用版）
················································································ 49 病案质量考核细则（北京版）
························································································ 55 住院病案（终末）书写质量检查表（七三一医院版）
················································· 58 七三一医院病案质量考核细则（等级评审版）
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第一部分
病案管理 医院病案管理领导小组
为了进一步加强医院的病案管理，充分发挥委员会的职能，根据医院人员变化情况，经院研究决定，对医院病案委员会及办公室成员进行调整，现将调整后的委员会组成和职责下发给你们，望积极配合开展工作。
一、病案管理委员会成员及职责 （一）病案管理委员会组成 主
任：张凤珍
副主任：张宝忠 顾
问：杨
光
李墨琴
赵素焕
张仁成 委
员：申素芳
邱丽艳
魏志宇
王玉霞
王晓光
杨
光
赵丽玲
刘宇明
陈
洪
申
彪
俞汉蒙
刘黎亮
王
冠
杨世斌
冯宗承
杨兆静
张志刚
代明岩
金
丽
王好真
周树杰
黄建锋 （二）病案管理委员会职责 1.全面负责医院门诊和住院病案资料的管理工作，密切配合临床、教学和科研工作。
2.听取病案管理工作的汇报；研究、协调和解决有关医院病案管理方面存在的问题。
3.制定适应本医院的病案系统和有关病案管理的规章制度； 4.督促指导病案管理工作，提出病案管理工作的改进意见； 5.拟定有关医疗及医疗统计的各种表格，审批这些表格的初印和复印； 6.组织各种形式的病案质量检查，促进病案书写质量的不断提高。
二、病案质量控制办公室设在医务处。
（一）办公室组成 主
任：申素芳 成
员：郑爱民
窦圣艳
单瑛
（二）办公室主要职责 1.每月组织各科质量组长检查全院的运行病历质量； 2.每年举行一次全院病历质量评比，并对全院质控病历进行分析总结； 3.负责日常病案质量控制工作，并收集科室对病案管理工作的意见建议，定期向病案委员会汇报。
4.设会议记录和病案检查记录本，凡会议有关活动及病案检查情况均做详细记录； 5.负责日常病案质量控制工作；
— 2 — 6.负责病案复印等相关问题的审批工作。
7、完成病案委员会交办的其他工作
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病案室工作制度
1.严格按照《病历书写基本规范》和《医疗机构病历管理规定》、《医疗纠纷预防和处理条例》、等有关法规、规范管理病历（案）。
2.为每一位就诊患者书写符合《病历书写基本规范》要求的病历，按现行规定保存病历资料，保证可获得性。
3.加强安全管理，保护病案及信息的安全。病案库有防盗、防尘、防湿、防蛀、防高温措施。
4.病案科工作人员知晓应急预案及处置流程。科室定期进行安全检查，对存在问题和缺陷及时改进。职能部门定期对病案科的安全管理进行检查指导，及时消除隐患，保障安全。
5.采用国家相关部门发布的疾病分类ＩＣＤ10 与手术操作分类ＩＣＤ9-ＣＭ-3，对出院病案进行分类编码；建立科学的病案库管理体系，包括病案编号及示踪系统，出院病案信息的查询系统。
6.严格执行借阅、复印或复制病历资料制度，防止丢失、损毁、篡改、非法借阅、使用和患者隐私的泄露。
病案收集制度
1.每日出院病人病历由各科负责的医务人员整理后，按出院登记保证病历完整，并填写交接单。
2.病案室病历收集人员，每天到各科下收出院病历，并做好签收记录，避免病历丢失。
3.出院病案的收集要依据病房出院病人报表的登记情况进行收集。应在病人出院 3 日之内将所有出院病案全部收回。
4.医师不得以任何理由未能及时完成病案记录，导致病案不能全部收回。特殊情况下未能按时收回的病案应向医务处报批并有记录。
5.主管医师注意收取滞后的检验报告单，如病理报告等在报告出具 48 小时内存入在病历中并记录病程，保证病历资料的完整性。
6.病案室与职能部门对患者出院后病历未能及时回归病案科的科室进行追踪、分析、改进管理，保障回归率。
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病案整理制度
1.出院当日主管医师必须逐页检查完善出院病历，包括病人姓名、病案号，病案书写是否完整，各种必要的检验回报是否齐全，各项记录是否完整等，保证终末病案资料的准确与完整。
2.科室相关人员及时对病历进行正确排序并做好出院登记。
3.科室病历质控人员 3 日内完成病历质控工作，并做好签字工作。
4.病案室相关人员每日定期到...
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