谈纸质病案的数字化

Discussion on the Digitization of the Paper Medical Records

目的探讨当下医疗机构纸质病案数字化管理的可行性和必要性。方法通过对纸质病案数字化前后医院病案资料管理工作的特点和使用,全面进行分析和比对并对具体实施方法进行论证。结果纸质病案数字化管理的实施在使用效率,资料安全、规范管理、服务范围及节省储存空间等方面提供了更多的支持。结论病案资料的数字化是医院发展的需要,提升了病案管理的信息化程度,提升了医院质量管理,解决了当前病案保存、科研利用、数据共享等诸多方面问题的一种实用、有效的管理方式。

Objective To explore the feasibility and necessity of the digitalized management of the medical record in modern medical institutions. Methods To conduct comprehensive analysis and comparison on the characteristics and apply of the medical records materials management work before and after the application of the digitalized medical records, and demonstrate the specific implementation methods. Results The implementation of digitalized medical records management has provided more support to aspects such as efficiency, security, standard administration, service area and saving storage and so on. Conclusions The digitalizatinn of medical record is necessary for the development of the hospital, and will not only improve the informatization degree, but will also boost the quality management. This man- agement mode solves the problems of the storage of medical records, scientific research and data sharing, which proved to be a practical and effective way.