What is the process of medical record management?

Medical record management process: 1. Daily management (1) is responsible for the centralized management of hospital medical records. (2) All discharged medical records should be recovered from the medical record room within three days after the patient is discharged (including death). (3) To be responsible for sorting, checking, registering, indexing, cataloging, binding and keeping the medical records of discharged patients. When handing over the medical records to the ward, register the hospitalization number, name, discharge date and delivery date one by one, and both parties shall sign in each handover registration office. (four) the computer group and the medical record administrator to handle the transfer procedures of medical records, conscientiously do a good job of medical record entry and verification, and make forms and print accounts every month. The second is the medical record keeping and supply 1, which is responsible for clinical, teaching and scientific research, as well as the supply and recovery of personal medical records. 2, responsible for hospital medical record excerpts and foreign reception with the consent of the medical department. 3. Cooperate with statisticians to sort out and analyze relevant statistical data. 4. The writing quality of initial medical records promotes the continuous improvement of the writing quality of medical records. 5. Do a good job in the safety of the medical record storage room and keep the contents of the medical record confidential. 6, hospital medical records should be kept by the medical record room for a long time, responsible for all kinds of data collection, sorting, classification, statistics, registration, numbering, shall not be lost or damaged, to keep clean and properly kept. And provide accurate and timely information needed for medical treatment, teaching and scientific research, as well as the examination and approval procedures for receiving foreign visits and borrowing and copying medical records. 7. The original data of medical statistics should be based on medical records, and only the information reflected by the contents of medical records is the most true and accurate, so hospitals should closely cooperate with statistical work and medical record management. 8, medical record room staff must strictly keep all the secrets in the medical record, shall not be arbitrarily leaked. 9, medical record room staff should carefully check whether the quality and content of medical records are systematic and complete, put forward the existing problems, and constantly put forward improvement methods. 10, the patient needs to consult the in-patient medical records and submit them to the medical record room by the outpatient doctor. 1 1. Medical records used to improve scientific research and analysis should be read and filed in the medical record room. If it is necessary to check it out, it must be approved by the medical management department and go through the borrowing procedures before it can be checked out and returned within two weeks. If it cannot be returned within the time limit, it shall be renewed in the medical record room, but it shall not exceed one month. 12. Non-medical personnel outside the hospital and in our hospital are not allowed to consult medical records. The medical records of senior doctors must be approved by the department director, but it is not allowed to borrow the medical record room. 13. Doctors in our hospital are not allowed to consult medical records unrelated to their major. If necessary for special reasons, it must be signed by the medical department or the doctor-patient office. 14. Copy the medical records and file them. According to the requirements of Medical Records Management Regulations of the Ministry of Health, medical records filed after September 1 day, 2002 can be copied. When copying, the staff in the medical record room should go to the designated place according to the copy certificate of the patient or his family, and copy the relevant contents according to the regulations. No other institution or individual may consult or copy medical records without authorization. 15. Any department or individual must go through the formalities when discussing and reading medical records in the medical record room. 16. Patients and their accompanying personnel are not allowed to read medical records. The flow of medical records between various departments in the hospital should be transmitted by relevant staff, and should not be carried by patients or their accompanying personnel.