入库前病案示踪系统的建立与应用

The establishment and application of preput in storage medical record tracing system

目的探讨入库前病案示踪系统的建立与应用。方法利用从电子病案系统导出的出院患者电子清单和科室提交纸质病历的手写清单为基础,建立入库前病案示踪系统,用于病历催交、工作量分配、病案示踪等方面。结果入库前病案示踪系统可实现多种应用,使病案管理工作进一步计算机化和规范化,提高了工作效率。结论以清单形式构建的入库前病案示踪系统是实现病案零丢失的简便、经济、有效手段。

Objective To explore the establishment and application of pre-put in storage medical record tracing system. Methods Utilized the discharged patients＇ electronic detailed list which exported from electronic medical record system and the hand-write detailed list which came from clinical department presented medical record to establish a pre-put in storage medical record tracing system, used for expediting medical record, assigning workload, tracing medical record, etc. Results The pre-put in storage medi- cal record tracing system was realized multiple application. Made the medical record management further computerized and stan- dardized, improve efficiency of work. Conclusion The pre-put in storage medical record tracing system established by the form of detailed list was a simple, economic and effective method to realized the zero lost of medical record.