中美教学医院门诊病历管理对比研究

Comparison of the Management of Out-patient Record in Teaching Hospitals in China and United States

通过文献检索、走访调研并结合笔者对美国教学医院门诊病历管理的实地考察,本文对中美两国教学医院人员对门诊病历管理的认识理念、门诊病历管理的方式、病历的规范设计以及门诊病历的质量控制等方面进行了对比研究。显示我国教学医院在门诊病历管理方面与发达国家存在着差距。从提高临床医疗和医学教学质量、有利于患者疾病的诊治和培养当代优秀医务工作者,促进医学科学技术发展出发,教学医院管理者和临床指导医生应高度重视和规范门诊病历管理。

By the literature retrospect, on--site survey and the author＇s experience in the teaching hospitals of United States, this paper study and compare the out--patients medical records in both countries on the philosophy, management style, design and guideline as well as quality control. Compared with the developed country, the gap really exists in the management of out-- patient records in our medical teaching hospitals. In order to improve medical teaching quality and clinical training quality, to bring up high quality medical provider, and develop medical technology of science, the manager and clinical trainer in teaching hospital of our country shall attach great importance on the standardized management of medical records.