精神科门诊病案中姓名索引的采集与管理

Collection and Management on Name Index in Out-patient Medical Records of Psychiatric Department

病案资料的准确性和完整性是医务人员对患者执行医疗护理计划的依据。由于病案信息不完整、不准确、不完整和失真,引发各种医疗纠纷。这一问题在精神科医疗中更凸显其重要。本文结合工作实际,对患者姓名索引的采集,采取的一些相应的管理方法和具体做法,谈几点体会。

The accuracy and integrity of medical records is the evidence that medical staffs practice the medical care program into patients. Medical records information is incomplete,inaccurate and distorted,contributing to various medical disputes,which is significantly important in psychiatric health care. In this article,name indexes of patients are collected combining with actual work and several experiences are also shared in terms of some corresponding management methods and specific practices.