双轨制模式下的纸质病案管理

Paper-based Medical Records Management under the Double-track Mode

在电子病历与纸质病案共存的双轨制模式下,纸质病案的重要性慢慢的被忽视了,纸质病案的管理中存在病历打印与签名不及时、检验与化验单丢失、病案回收不及时等问题。应提高领导及各级医务工作者的重视和认识,加强病案的监控,将病案管理与绩效考核挂钩,从而保证病案质量,减少医疗风险。

The importance of Paper-based medical records gradually being neglected under the double-track mode of electronic medical records coexist with Paper-based medical records. There are many problems in the .management of paper medical record such as print and signature is not timely, inspection and laboratory test reports to be lost, medical record recovery is not timely. We ensure medical record safety and reduce medical risk by improving the attention and awareness of leadership and medical workers at all levels, strengthen the monitoring of medical record, link medical record management to performance evaluation.