规范住院病历表格管理的做法与思考

The Practice and Thinking on Standardization of Medical Record form Management

根据国家卫生部要求,制定并实施住院病历表格管理制度,对其使用与废除、内容与格式、纸张与印制等工作进行规范,使住院病历表格更加统一,增强了住院病历的法律效力,为实施电子病历打下了基础。

According to the requirements of Ministry of Health,it needs to establish and implement the management system of medical record form,regulating the usage and abolition,content and format,paper and printing,in order to standardize and normalize the medical record form,enhancing the legal force of medical record which makes the foundation for electronic medical record implementation.