See medical records jokes

The medical record is a humble thing. Before the popularity of electronic medical records, we had to spend a dollar to buy a small blueprint for doctors to record, but many people may not go to the hospital several times a year and don't know where to throw the medical records after seeing the doctor. Later, electronic medical records became popular, and doctors recorded their illness directly in the computer when they saw a doctor. As for what was written, few people paid attention to it. However, you may never have thought that every word written on the medical record is related to whether you can buy insurance in the future! Can I pay for the insurance I bought?

A real case comes from my friend Mix. About two years ago, she went to the gastroenterology department of a hospital in Beijing because of her stomach discomfort. In order to let the doctor judge her health more accurately, she told the doctor all the uncomfortable symptoms she felt before. Results It was clearly written in the medical record that non-atrophic gastritis with gastroesophageal reflux and simple gastritis, in fact, there was no big problem when insured, just because of most critical illness insurance. In Mix's words, "disaster comes from the mouth" is similar.

In addition, Bian Xiao has been engaged in insurance for so long, and heard and contacted many cases that could have been settled, but he was eventually refused insurance because of a wrong word written in his medical record.

So you see, it is really important to write correct medical records, especially those friends who have already bought insurance and want to buy insurance.

Why is the medical record so important?

Because it is the basis of health notification and the proof of insurance claims.

1) Health notification is subject to medical records.

Many friends will ask when they apply for insurance: I have had xx disease before, but I can't find the medical record. Should I tell you?

This question is actually difficult to answer. I have had a certain disease, but it is difficult to give an accurate answer without knowing the specific symptoms and indicators.

At present, the national regulations on medical record preservation: outpatient (emergency) consultation medical records are kept by medical institutions, and the preservation time is 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.

If you go to the hospital, I suggest you prepare a small blueprint, especially now many hospitals are mainly electronic medical records. After seeing the doctor, you basically don't know what the doctor wrote, which has great hidden dangers. It is suggested that you print your own electronic medical records on the hospital self-service machine every time you see a doctor and save them. As for whether the insurance conforms to the health notification, it mainly depends on the situation written on the medical record.

2) Medical record is an important proof of claim settlement.

When we apply for claims, the insurance company's first step is to survey claims, in which medical records are a very important carrier. The medical records in the early years were all handwritten, and writing and preservation were not particularly standardized. It is time-consuming and laborious to investigate, and it is inevitable to miss the net. However, since April last year 1, the state has implemented the Provisional Regulations on the Management of Electronic Medical Records, and the possibility of such omissions is almost zero.

For a simple example, Mr. A was diagnosed with myocardial infarction and underwent contrast stent surgery. According to the contract, this has been covered by the critical illness insurance, but the insurance company refused to pay, because when Mr. A was admitted to the hospital, he remembered a chest pain five years ago and told the doctor. Later, the doctor recorded in the medical record: "Intermittent chest pain for 5 years, aggravated for one week." Does not meet the "Does the insured have chest pain in the last year" in the health notice. So the insurance company made a decision to refuse compensation.

Therefore, whether insurance can compensate depends on the product terms on the one hand and the contents of medical records on the other. Only when the conditions are met can you get a claim.

As for how to write medical records, it will be more advantageous. Here are some suggestions for everyone:

1) When you see a doctor, tell the doctor that you have commercial insurance, and the doctor can understand you.

At the last physical examination, the doctor said there was a little hyperplasia of mammary glands. Although this problem didn't have much impact when I took out insurance, I told the doctor that I had insurance, so the final medical report didn't show up.

2) Try not to appear in the medical records: primary, congenital, recurrent and other words.

Many people go to the hospital to see a doctor and tell the doctor without reservation. Is it certain or uncertain, such as "my family seems to have a genetic disease", "my mother has gastritis, and I may have it". They may be recorded by doctors. If you buy medical insurance and critical illness insurance, you should pay special attention to these situations, which is likely to make the insurance company think that you have related symptoms before you buy insurance and deliberately ignore them when you buy insurance.

3) If you buy accident insurance, pay special attention to the description of the reasons.

For any injury caused by accident, try to let the doctor write down the cause of the accident on the medical record. Because when making a claim, you usually need to submit the claim application form, medical records, expense list and other materials. If the information about the accident in the medical record and the claim application form can be mutually verified, it can help the claim adjuster to make a judgment faster. In addition, don't write "injured or injured" at the beginning, because many accident insurance regulations stipulate that the damage caused by a third party shall be compensated by the third party.

4) Check the medical records in time. After the doctor has written the medical record, we'd better have a look at it in detail to see if the content conforms to our actual situation. If mistakes are found, you can ask the doctor to correct them immediately. In addition, when we later found out that the medical record was wrong, it didn't mean that there was no remedy at all. First of all, you can go to the attending doctor to make changes, but this process is very complicated, which requires the attending doctor to make changes, then the leader signs it, and finally applies for the official seal of the hospital to complete the changes. If the attending physician doesn't agree to change, don't lose your temper in a hurry and go directly to the "medical department" of the hospital to complain. This department specializes in handling medical disputes and complaints.

For some common mistakes, you can refer to the following methods:

If the name is misspelled, ask the hospital to reissue the case or issue a certificate to prove the doctor's clerical error. If the doctor doesn't change his previous name, he will have to go to the household registration unit to issue a certificate to prove that the name on the medical record is really me.

(2) Cases where typos need to be corrected. Don't let the doctor change or rub them at will. Previous handwriting should be preserved, not covered up or deleted. Let the doctor make corrections according to the Basic Norms of Medical Record Writing.

The wrong time to get sick is the illness after buying insurance. As a result, the doctor's mistake became a disease before buying insurance. In this case, it is best to add the official seal of the hospital to prove the authenticity of the medical record, in addition to letting the doctor revise it according to the basic norms of writing medical records.

Insurance claims have always been the most concerned thing in the process of buying insurance.

Many people think that if you cheat someone, the insurance company will refuse to pay, but in fact, it is often because of our own mistakes that we cheat ourselves, and the medical record is a typical representative.

In a word, I hope you can all realize the importance of this problem. When you see a doctor in the future, you should pay attention to your wording. Even if electronic medical records are popular now, they should be printed out in time to check whether what the doctor wrote is true or not, so as to avoid unnecessary troubles in the later period. This is very important, remember, don't forget!