After every visit, keep your own copy of the records, the test reports, and the images
Grade AMedium benefitMoneyFreeLittle timeSome willpower
Looking up and copying your own records is a right the law gives you. Outpatient records, the inpatient record, lab slips, images, surgery and anesthesia records, pathology material, and the bill can all be copied. The hospital has to name a department or a person to take the request, and it may charge only the materials fee. Changing hospitals, having another doctor look again, claiming on commercial insurance, and a real dispute all rest on this stack of papers.
- Cost
- No money. A hospital may charge a materials fee for copies, as the rules allow, and the fee schedule has to be public. The hard part is remembering to copy a set after every visit.
- Benefit
- The rules list looking up and copying the medical record as a patient's right. The scope covers the outpatient record, the inpatient record, lab slips, medical images, surgery and anesthesia records, pathology material, medical charges, and the rest of the file. Changing hospitals, having a second doctor look again, claiming on commercial insurance, and a real dispute all rest on these papers.
- Notes
- Copying is handled by the department the hospital names. You do not have to ask a doctor for a favor. For the list of what to copy, read out Article 16 of the Regulations on the Prevention and Handling of Medical Disputes. First come the outpatient record, the inpatient record, the temperature chart, the order sheet, lab slips, and images. Then come the surgery and anesthesia records, pathology material, nursing notes, and the medical bill. After you have them, file them in time order. What matters most in the folder is the discharge summary, the operative note, the pathology report, and the key images. Write each round of chronic-illness readings in the same notebook. See Section 16.
Sources · 2
- 国务院 (2018). 医疗纠纷预防和处理条例（国务院令第 701 号）第十六条：「患者有权查阅、复制其门诊病历、住院志、体温单、医嘱单、化验单（检验报告）、医学影像检查资料、特殊检查同意书、手术同意书、手术及麻醉记录、病理资料、护理记录、医疗费用以及国务院卫生主管部门规定的其他属于病历的全部资料。」「患者要求复制病历资料的，医疗机构应当提供复制服务，并在复制的病历资料上加盖证明印记……可以收取工本费，收费标准应当公开。」「患者死亡的，其近亲属可以依照本条例的规定，查阅、复制病历资料。」第十五条「任何单位和个人不得篡改、伪造、隐匿、毁灭或者抢夺病历资料。」gov.cn/zhengce/zhengceku/2018-08/31/content_5…
- 国家卫生计生委、国家中医药管理局 (2013). 医疗机构病历管理规定（2013 年版）：医疗机构「应当指定部门或者专（兼）职人员负责受理复制病历资料的申请」，复制在申请人在场的情况下进行并加盖证明印记. gov.cn/gongbao/content/2014/content_2600084.htm