病案管理由传统模式向现代化模式转型的体会

Experience on the Transition of Medical Records Management from Traditional Mode to Modern Mode

目的探讨病案管理由纸质的传统模式向电子病案的现代化模式转变过程中存在的利弊问题,以便制定相应的制度,从而加强质量管理及提高病案利用率。方法观察分析由传统纸质病案向电子病案转变过程中出现的问题。结果病案管理流程简化,医疗工作的效率提高;但是由于法律上的空白,导致纸质病历的继续存在。结论加强病案及医护人员计算机操作能力的培训,提高责任意识及法律意识,强化职能部门对病案环节质量管理。

Objective To explore the advantaged and disadvantages existing in the transition from traditional mode focused on medical records in paper form to modern mode in electric form for the management system,which contributes to the establishment of relevant regulations and improvement of quality management and utility rate of medical records.Methods Problems appearing during the transition period from traditional paper medical records to electric medical records were studied and analyzed.Results Simplification of management process of medical records and improvement of medical service efficiency are realized,however paper medical records are still in use due to legal limbo.Conclusion It is necessary to strengthen the training of computer operation skill for medical records staffs and medical care staffs,improve their responsibility and legal awareness,and strengthen the quality management of medical records by functional departments.