从医保的角度看病案书写中存在的问题及对策

随着医疗保险工作在我国的全面实施，病案的对外功能显著增加，病案的书写质量面临新的挑战。在医保审核过程中发现病案书写存在问题，主要表现在基本信息、诊断、现病史、既往史和检查用药方面，为了维护医院、患者、医保机构的合法权益，应对医务工作者进行社保知识学习；加强病历书写培训和监督奖惩；建立病历质量控制体系。

A Consideration of the Problems in the Documentation of the Medical Records in the Light of Health Insurance and the Countermeasures

With the implementation of health insurance in our country, the external use of the medical records make new challenges in the quality of the documentation of the medical records. In the process of auditing the documents of health insurance, we found the problems in the documentation, which are mainly revealed in the aspects of the basic information, diagnosis, current medical history, past history, examination and medication. Protecting the rights and interests of the hospital, patient and medical insurance institution, we should train the medical workers for health insurance and documentation, and the systems of the rewards and penalties and quality control should be established.