病案表格的设计与管理

Medical Record Forms Design and Managenent

一份设计合理的病案表格是保证病案质量的前提和基础。随着临床医学的发展,临床工作方法流程发生了一些变化,病案管理者必须依据临床工作的新特点不断改进和完善病案表格的格式和内容,同时病案表格在设计上还需要满足当前"举证责任倒置"的法律要求。医院应在制度上加强病案表格的管理,使管理工作规范化,法制化。医院数字化信息系统的广泛应用对病案表格管理提出了更高的要求,病案管理者必须依据新形式、新特点探索新的病案表格管理模式。

A well designed medical record form is the precondition of high quality medical record management.Along with the rapid development of medical science,some changes happened in clinical work.Format and content of medical record form has to be revised and improved constantly according to the changes in medical work.At the same time,medical record form should meet the requirement of law of ＂the shifting of burden of evidence＂.Additionally,hospital should institutionally strengthen management of medical record form to insure the management is normative and legal.A higher requirement of medical record form management has been made in the process of wide use of hospital information system,new management pattern should be explored in this background.