How do I get a copy of the medical record? What procedures do you need to go to the hospital to copy

The procedure for copying medical records is that the patient himself or a person entrusted by the patient must first bring his or her ID card to the medical office of the hospital, and the medical office will stamp the official seal after approving the slip, and then go to the medical record room to make a copy. Patients sometimes only know how to make copies of medical records, but not about seizures. Medical institutions generally do not take the initiative to tell patients to seize medical records.

To seal the medical records, both the doctor and the patient should be present, make copies of the original medical records, and put the original in a pocket for the patient.

Write the date on it and sign and stamp it (or fingerprint). After the original is seized, it is placed in the medical office, because it has the patient's signature on it, so there is no need to worry about anyone moving around. In the future, a photocopy will be used for lawsuits, and if necessary, the original medical records of the hospital will be required.

Why are medical records being seized? Because the copy of medical records can only copy the parts stipulated by the state, such as the medical records of the first day of hospitalization, body temperature sheets, doctor's orders, various laboratory test sheets, pathology reports, etc. If surgery has been performed, the surgical consent form can also be photocopied, including anesthesia sheets, surgical records, nursing records, etc.

Patients are not allowed to make copies of all the medical information they need. The information is objective and has not been subjected to any subjective analysis. However, there are some materials that cannot be copied according to regulations, such as the medical records recorded by the doctor every day (including consultation records, case discussions, etc.).

Therefore, the copying of medical records and the seizure of medical records must be carried out at the same time. The seizure was of an entire set of medical records. If a patient is hospitalized for three days or five days, there may be no difference between the photocopied medical records and the sealed medical records, but if the patient is hospitalized for a long time, the daily medical record is very important.

The doctor's careful observation every day, the accuracy of the judgment of the condition, and the best measures taken can be reflected. If the patient suspects that there is a problem with the blood transfusion, infusion or injection used in the hospital, the hospital and the patient should also seal the physical object, and then both parties should take the seized physical object to a qualified department for testing. In addition, a list of expenses such as medication, companion expenses, transportation expenses, and lost work expenses during the patient's medical treatment, as well as evidence related to medical treatment, should be kept.

The advantage of keeping these notes is that they are evidence of favorable compensation once the hospital is negligent in the court.

Well, if you have an acquaintance in the hospital, you don't need any documents, and the doctor can borrow it directly by writing a note to the archives.

Can you ask the hospital, where is their medical record room in? Go to ** say your name, and provide your ID card if you say it, not if you provide proof of relationship. Because this is not a casual look, ask me if you don't understand.

You can usually get it after three days of discharge.

To go to the hospital to copy medical records, you need to apply to the hospital department and provide a valid identification or material certificate. After a medical establishment accepts an application for copying medical records, it shall provide them after the medical personnel have completed the medical records within the prescribed time limit (usually three days).

Legal basis] Article 17 of the Regulations on the Management of Medical Records of Medical Institutions.

Medical establishments shall accept applications from the following persons and institutions to copy or review medical records, and provide services for copying or reviewing medical records in accordance with regulations:

1) The patient himself or his or her delegates;

2) The legal heirs of the deceased patient or their ** persons.

Article 18. Medical establishments shall designate departments or full-time (part-time) personnel to be responsible for accepting applications for reproduction of medical records. When accepting an application, the applicant shall be required to provide relevant supporting materials, and the form of the application materials shall be reviewed.

Hello, (1) The applicant shall submit relevant supporting materials when applying, and shall provide valid proof of identity and relationship if the patient himself and his ** person apply; If the applicant is an insurance institution, a copy of the insurance contract shall be provided. (2) Review the application and provide reproduction. After the application is accepted, it shall be provided after the medical personnel have completed the medical records within the prescribed time limit.

After a medical institution accepts an application for copying or reproducing medical records, the department responsible for the quality control of medical services or the department or ward where the full-time staff is responsible for keeping the outpatient (emergency) medical records.

1. The patient himself or the person entrusted by the patient should bring his ID card and medical records to the medical office of the hospital;

2. The medical department stamps the official seal after approving the medical record;

3. Then go to the medical record room to redistribute the return seal. After making a copy of the original medical record, put the original in a pocket and ask the patient to write the date on the dust ear and sign and seal it;

4. After signing and stamping, the medical file student will use a photocopier to copy the medical record;

5. At this time, the medical record will be copied.

The contents of the case can be copied in: outpatient medical records, inpatient records, body temperature sheets, doctor's orders, laboratory tests (test reports), medical imaging examination materials, special examination consent, surgical consent, surgical and anesthesia records, pathological data, nursing records and other medical records stipulated by the health administrative department.

For hospitals, the following materials need to be prepared for medical evaluation:

1. Original medical records such as inpatient disease course records, death case discussion records, difficult case discussion records, consultation opinions, and ward rounds of senior physicians;

2. Inpatient hospitalization records, body temperature sheets, doctor's orders, laboratory tests (test reports), medical imaging examination data, special examination consent forms, surgical consent forms, operation and anesthesia records, pathological data, nursing records and other original medical records;

3. Rescue the critically ill patient and make up the original medical record data within the specified time;

4. Seal and retain physical objects such as infusions and injections, blood, and drugs, or the inspection reports made by inspection institutions with inspection qualifications in accordance with the law;

5. Other materials related to the technical appraisal of medical malpractice.

For outpatient and emergency patients who have medical records in medical institutions, their medical records are provided by the medical institutions; If there is no medical record file established in the medical establishment, it shall be provided by the patient.

Legal basisArticle 10 of the Regulations on the Handling of Medical Accidents.

Patients have the right to copy or reproduce their outpatient medical records, hospitalization records, temperature sheets, doctor's orders, laboratory tests (test reports), medical imaging examination materials, special examination consent forms, surgical consent forms, surgical and anesthesia records, pathological data, nursing records and other medical records prescribed by the health administrative department.

According to the relevant laws and regulations, the applicant may copy or reproduce the medical record information, including: hospitalization records, temperature sheets, doctor's orders, laboratory test sheets, medical imaging examination materials, special examination consent forms, surgical and anesthesia records, pathology reports, nursing records, and discharge records. Public security and judicial organs that need to consult, copy, or reproduce medical records for the purpose of handling a case shall issue a statutory certificate for the collection of evidence and a valid identification certificate for the personnel performing public duties, and review it by the medical affairs department.

The following supporting materials are required to make copies of medical records:

1) If the applicant is the patient himself/herself, his/her valid identity certificate shall be provided;

2) If the applicant is a patient **, the patient and his ** person shall be provided with valid identity certificates, as well as legal proof materials and power of attorney for the relationship between ** person and patient **; Public security, procuratorate, law and other authorities must also provide relevant supporting documents to copy patients' medical records.

3) If the applicant is the legal heir of the deceased patient, the patient's death certificate, the valid identity certificate of the deceased patient's legal heirs, and the legal proof of the relationship between the deceased patient and the legally-designated heirs shall be provided;

4) If the applicant is the legal heir of the deceased patient, Qiaochang shall provide the patient's death certificate, the valid identity certificate of the deceased patient's legal heirs and their ** person, the legal proof materials of the relationship between the deceased patient and the legal heir, the legal proof materials of the relationship between the deceased patient and the legal heir, and the power of attorney.

What is a medical record:

The medical record is a record of the medical staff's medical activities such as the occurrence, development, and prognosis of the patient's disease, as well as the examination, diagnosis, and other medical activities. It is also a medical and health record of patients who summarize, sort out and comprehensively analyze the collected data, and write them in accordance with the prescribed format and requirements. The medical record is not only a summary of clinical practice, but also a way to explore the laws of diseases and deal with medical disputesLegal basisIt is a valuable asset of the country.

Medical records play an important role in medical treatment, prevention, teaching, scientific research, and hospital management.

Legal basis

Regulations on the Management of Medical Records of Medical Institutions

Article 7: Medical establishments shall establish a numbering system for outpatient (emergency) medical records and inpatient medical records.

Outpatient (emergency) medical records and inpatient medical records shall be marked with page numbers.

Article 8: The outpatient (emergency) medical records of patients who have outpatient (emergency) medical records in medical establishments shall be delivered to the patient's department by a designated person designated by the medical establishment; Where patients are treated in multiple departments at the same time, the medical establishment shall designate a special person to deliver them to the follow-up department.

Within 24 hours after the end of each diagnosis and treatment activity, the patient's outpatient (emergency) medical records shall be recovered.

Article 19. Medical institutions may copy the body temperature list, doctor's order, hospitalization record (admission record), surgical consent form, anesthesia consent form, anesthesia record, surgical record, nursing record of seriously ill (critically ill) patients, discharge record, informed consent form for blood transfusion, special examination (special**) consent form, pathology report, test report and other auxiliary examination reports, medical imaging examination materials and other medical record materials in the outpatient (emergency) medical record and inpatient medical record.

Copies of medical records include the first page of the medical record, medical course records, various examinations such as laboratory tests, ultrasound, electrocardiogram, **, CT, etc., doctor's orders, thermometers, other medical documents such as surgical informed consent, etc., and discharge records.

Smooth copying of medical records usually requires these 4 steps:

1. Understand the time taken by the hospital to copy medical records.

When the patient's diagnosis and treatment is completed (after discharge), the hospital should organize and archive the personal medical records. Generally, this process takes 10 to 15 days, so most hospitals wait 10 to 15 days after the end of the consultation before they can make a copy of the medical record.

2. Prepare relevant materials.

Whenever there is a need to provide materials and documents, there are always some people who repeatedly run to the hospital because the materials are incomplete, which is time-consuming and laborious. Therefore, it is very necessary to prepare the materials in advance.

Generally speaking, the required documents need to be decided according to the person who applies for a copy of the medical record, which is roughly divided into the following five types:

The applicant is the patient himself/herself.

Required documents: Valid identification of the patient.

Valid identification documents include resident identity cards, household registration booklets, social security cards, Mainland Travel Permits for Hong Kong, Macao and Taiwan or other valid documents, military identity documents, passports, etc.

The applicant is a patient (e.g., relative, friend).

Materials required: Valid identification of the patient and his/her ** person.

Statutory proof of the relationship between the applicant and the patient** (power of attorney).

The applicant is a close relative of the deceased patient.

Materials required: Patient's death certificate.

Valid proof of identity of the applicant.

The applicant is a close relative of the deceased patient with legal proof materials (such as marriage certificate, household registration booklet or certificate of village neighborhood committee, etc.).

The applicant is a close relative of the deceased patient.

Materials required: Patient's death certificate.

Valid identification of the deceased patient's close relatives and their ** persons.

Statutory proof of the relationship between the deceased patient and his close relatives (such as marriage certificate, household registration booklet or certificate of village neighborhood committee, etc.).

Statutory proof of the applicant's relationship with the deceased patient's close relatives** (e.g. power of attorney).

The applicant is an insurance institution.

Documents required: A copy of the insurance contract.

A statutory certificate issued by the insurance department to obtain medical records.

Valid identification of the undertaker.

Statutory proof of the patient's consent or his/her consent.

In addition, when the insurance institution applies for a copy of the medical record, but the patient himself has died, it also needs to provide the legal proof of the consent of the close relatives of the deceased patient or ** person (such as power of attorney). Except as otherwise provided by contract or law.

Legal basis

Article 7 of the Regulations on the Management of Medical Records of Medical Institutions.

Medical establishments shall establish a numbering system for outpatient (emergency) medical records and inpatient medical records, and establish a unique identification number for the same patient.

He Chun medical institutions that have established electronic medical records shall associate the medical record identification number with the patient's identification number, and the medical records can be retrieved by using both the identification number and the identification number.

Outpatient (emergency) medical records and inpatient medical records shall be marked with page numbers or electronic page numbers.

Legal analysis: To go to the medical record room to copy medical records requires personal identification procedures, and then submit an application for copying or copying medical records, the department or full-time (part-time) personnel responsible for medical service quality control shall notify the department (personnel) or ward responsible for keeping the outpatient (emergency) medical record files, and send the medical records that need to be copied or copied to the designated place within the specified time and copy or reproduce in the presence of the applicant.

Legal basis: Article 17 of the "Regulations on the Management of Medical Records of Medical Land and Field Therapy Institutions" After a medical institution accepts an application for copying or reproducing medical record data, the department or full-time (part-time) person responsible for the quality control of medical services shall notify the department (personnel) or ward responsible for keeping the outpatient (emergency) medical record files, and send the medical record materials that need to be copied or reproduced to the designated place within the specified time, and copy or reproduce them in the presence of the applicant. After the photocopied or reproduced medical record materials have been verified by the applicant, the medical institution shall affix the seal of the certificate.

Article 18: Medical establishments may charge the cost of production in accordance with regulations for copying or reproducing medical records.