"Regulations on the medical record management of medical institutions" revised interpretation 
 

The national health and family planning commission of the People's Republic of China 

 
www.moh.gov.cn2013-12-17 

        A, revision background
        (a) to strengthen medical record management of medical institutions, medical record information in an objective and true, complete, according to the "regulations on the administration of medical institutions" and "byelaw of medical accident treatment and so on laws and regulations, issued by the former ministry of health in 2002 to make the" regulations on the medical record management of medical institutions "(hereinafter referred to as the regulations), for the standardization of the medical record management of medical institutions, safeguard the legitimate rights and interests both doctors played an important role. With the development of social economy in our country and to deepen the reform of medical health care system, medical record management of medical institutions faces some new situations and new problems. In order to further strengthen the management of medical institutions, medical records management can meet the needs of modern medical management, medical administration hospital authority experts in 2002 issued the "regulations on the medical record management of medical institutions" was revised, and ask for the state administration of traditional Chinese medicine, by related departments, and 31 provinces (autonomous regions and municipalities) health bureaus (health and family planning commission) medical opinion, summary revision opinion after making 2013 version of the "regulations on the medical record management of medical institutions".
        Second, the principle of revision
        Revision on the main content of the 2002 edition of retention and perfect, at the same time in the new version of the regulation embodies the spirit of medicine and health care system reform related, reflects the new situation, new requirements for the management of medical records, and in recent years introduced related laws and regulations such as well.
        Three, the main changes
        (a) files systematic, organized to strengthen the whole.
In 2002 issued "regulations on the medical record management of medical institutions", a total of 23, did not divide the chapter. 2013 version of the regulation is divided into seven chapters, a total of 32, from general statements of principle, the establishment of the medical records, custody, borrow and copy, sealed and unsealed, made even more save and supplement the seven aspects such as system, clear rules.
        (2) the content is more detailed, specific and perfect.
        Revised the regulations to perfect the following contents: increase the scope of the regulations, clear the department of management of medical institutions in medical records quality, increase the medical record writing, sorting, and medical record binding and other relevant requirements, has been clear about the test results in or entry door (urgent) confirmed through requirements, the specific requirements of rules for borrowing, and increase the storage records and hermetical relevant provision, has been clear about the medical institution changes its name or revoked after preservation requirements, increase the hospital medical records, save time, revised the door (urgent) confirmed through the filing time.
        (3) increase the electronic medical records management related content, reflect the characteristics of medical record management under the new situation.
        Implements and realizes the central committee of the communist party of China for the opinions of the state council on deepening the reform of medical health system ", issued by the state council on medical and health system reform the key implementation plan (2009-2011), the notice and the state council general office on the five key medical health system reform in 2010 main work arrangement notice file spirit, such as the ministry of health has released in 2010 and 2010, the specification of electronic medical record system and notification file, widely used in electronic medical records in medical institutions. As a result, 2013 edition of the regulations on clear "electronic medical records and papery medical records have the same effect", and provisions of the relevant regulatory requirements.
        (4) with the relevant laws and regulations, standardization of cohesion.
        In recent years, the new "tort liability act" and "the medical record writing basic norms", "the medical record writing basic norms of traditional Chinese medicine", "basic standard (try out)" electronic medical records and electronic medical records of TCM basic norms "and other laws and regulations, standardize the medical establishment, modification, storage, storage, etc. Put forward new requirements. This revision notice and relevant laws and regulations, standardize the cohesion, reflect the new requirements.
In safeguarding the patients right of informed consent, the 2013 edition of the regulations on medical record content increased blood transfusion in the treatment of informed consent, special examination consent (special treatment), etc., and medical institutions to the applicant copy of the medical record content also increased blood transfusion in the treatment of informed consent, special examination consent (special treatment), etc.
        (5) accords with the practice of clinical work, rights and interests of both doctors pay more attention to maintenance.
        Medical records of 2002 edition rules seal can be a copy, but in practice often sealed original medical records. 2013 version specified medical record copy, sealing and unfinished after storage of medical records, medical records can continue to the original records and use, not only ensure medical records storage, and maintain the normal order of diagnosis and treatment.
 
 
 
 
Relevant link: about print and distribute the medical record management of medical institutions (2013 edition)"