If there is no kinship, if it needs to be extracted, the entrustment procedures, such as power of attorney, should be issued, indicating who authorized who to extract the relevant medical records of what diseases he saw in which hospital and at which time, and whether it included laboratory data.
It is very important to pay attention to whether there is the signature of the attending doctor when extracting medical records. Generally, according to hospital regulations, the attending doctor should sign the daily medical record, and sign it by hand, or put it on record and seal it in the hospital.
Medical record is a record of the occurrence, development, outcome, examination, diagnosis and treatment of patients' diseases. It is also a patient's medical and health record written in accordance with the prescribed format and requirements by summarizing, sorting and comprehensively analyzing the collected data. Medical records are not only the summary of clinical practice, but also the legal basis for exploring the laws of diseases and handling medical disputes, and are the precious wealth of the country. Medical record plays an important role in medical treatment, prevention, teaching, scientific research and hospital management. Medical records are not only the summary of clinical practice, but also the legal basis for exploring the laws of diseases and handling medical disputes, and are the precious wealth of the country. Therefore, when writing medical records, medical staff must be realistic, serious, scientific and meticulous. Medical record plays an important role in medical treatment, prevention, teaching, scientific research and hospital management.
1. medical care: medical records are not only the data for diagnosis, treatment and preventive measures, but also the basis for medical staff to evaluate the level of disease diagnosis and treatment, and it is also an important reference for the diagnosis and treatment of patients when they come back. By reviewing the clinical medical records, we can learn from them, improve our work and improve the quality of medical care.
2. Teaching: Medical records are valuable materials for teaching and the most vivid teaching materials. Through the writing and reading of medical records, the medical theory and practice are closely combined, the learned knowledge is consolidated, the horizons are broadened, and the logical thinking ability and rigorous medical style of medical staff and medical students are cultivated.
3. Scientific research: Medical records are the main data of clinical research. Through the summary and analysis of clinical medical records, we seek the objective laws and internal relations of the occurrence, development and treatment outcome of diseases, study the relationship between clinical treatment and preventive measures and diseases and rehabilitation, discover and screen new medical technologies and drugs, and promote the continuous development of medicine.