NHS to Further Strengthen Medical Record Management

The National Health Commission website on January 17 news, the General Office of the National Health Commission recently issued the "Notice on Further Strengthening the Management of medical documents such as Medical Certification Documents", which put forward unified requirements for strengthening the management of medical documents within medical institutions. First, improve the management system of medical documents. Medical institutions are required to establish and improve the management system for medical documents, sort out and formulate a catalogue of medical documents, clarify the conditions for issuing medical documents and carry out dynamic management, and implement the separation requirements of certificates and seals. The second is to unify the contents of medical documents. Medical institutions are required to unify the format of their medical documents, clarify the basic norms or requirements of the content of medical documents, and establish a unified numbering and retention backup mechanism. The third is to standardize the issuing of medical documents. Medical institutions are required to strengthen the behavior management of issuing medical documents by their own physicians from all aspects. Fourth, strengthen the management of medical document verification. Medical institutions are required to establish a backtracking verification mechanism and strengthen the quality management of medical document results. The fifth is the responsibility of compacting medical documents. Medical institutions are required to establish a mechanism to investigate the responsibility of medical documents, strengthen the sense of responsibility of medical staff, and ensure the quality of medical documents.