Research On The Present Situation Of Medical Record Management And The Relevant Legal Issues Of X Province

Objectives: This paper,based on the analysis of the present situation of medical record management of X province and discussion of the relevant legal issues,puts forward a few suggestions and countermeasures to improve the awareness of medical record management and the legal aspects.It also strives to provide evidence for the management improvement of medical records of X province and provide reference for others.Methods: The Prevalence study is carried out to investigate and evaluate the present situation of the medical record management,and both the literature analysis and expert interview are applied to discuss about the legal issues related.Results:(1)Medical record room.Only 20.6% of all the medical organizations investigated have separate medical record rooms,which are distributed under different other administrative sections in the rest 79.4%.(2)Staff member.The sex ration of the male workers to the female workers is 1:3.27.The majority of all the staff members has intermediate and elementary academic titles and has a college diploma or a bachelor degree majoring mostly in health care,and in clinical practice.(3)The importance attached on the management of medical record.(1)Only 17.6% have attached great importance on the medical record management.Less attention is paid in other 44.1%and even less in others.(2)35.3% have maintained the medical records for more than 90% of all the patients and 14.7% have classified more than 90% of all the medical records on time.Only 5.9% have lowered the correcting rate to less than 2%.(3)The informational management of medical record.70.6% use the digital medical record systems and none has applied the e-record management system,the bar code management system or the record tracking system.(4)The content of record copy.82.4%offer to copy the objective content and 2.9%,the comprehensive content,and 14.7%,both.(5)The preservation of medical record.There different requirements concerning the preservation of medical records in terms of preserving body,object and length of preservation.(4)The awareness of record management.(1)The key procedures in medical record management are writing,keeping,copying,preserving and using.(2)Only 22.2% of the medical staff members have read about the regulations of medical record management(updated in the year 2013).(3)Staff members have different understandings on the ownership of the medical records for the out-patients and the in-patients.(4)The main problems existing in record writing include,incomplete formal consent from the patients,missing signatures from the nurses and inconsistent records from the doctors and the nurses.(5)Some medical records are not classified in time and some are not well kept with some contents missing,stolen or even destroyed.(6)The legal validity of the incomplete medical records is not fully comprehended.(7)There is not an agreement on the informed consent from the patients in terms of the informing object,time,content and way.Conclusions: The present situation of medical record management in X province cannot adapt to the rapid development of medical technology and the management mode is unordered with inadequate fulltime staff,low-quality writing skills and insufficient legal and self-protection awareness.Legal issues in medical record management:(1)The ownership is not clearly stated.(2)There exist some legal problems in record writing.(3)There are cases of missing records.(4)The contents allowed to be copied are not specified.(5)There are some argument on the preservation of medical records in terms of the main body,form,and length.(6)What should be done about the incomplete medical records.(7)How to inform the patients and get their consents.The paper,through the investigation of the present situation of medical record management in X province and the detailed analysis of the relevant legal issues,tries to put forward a few measures to solve the legal problems in future management practice,and suggests that the primary emphasis should be laid on how to avoid the predictable tension between doctors and patients in medical record management.