保持病案可获得性的对策

The Countermeasures of Keeping the Medical Record Availability

病案作为珍贵的医学资料使用范围日益广泛,保持病案可获得性更显重要。本文通过分析某二级综合医院病案管理工作中存在的具体问题,从病案的归档、存储、借阅三方面加强库房管理提高病案的可获得性。采用了以下措施包括建立科室归档率通报制度,完善病案回收监控体系,达到出院病案及时归档;加强病案库房管理,健全库房管理制度,成立病案检查小组,达到安全、有序、科学存储病案;加强对病案借阅环节的管理,健全病案借阅制度,建立抽查制,达到病案流通中的"零"丢失;采用数字化病案管理模式,应用扫描、条形码技术等,能够有效实现保持病案可获得性这一目的。

Medical record as valuable medical information is becoming more and more widely used. Keeping the medical record availability is more and more important. In this article, through analyzing some specific problems existing in the secondary general hospital medical record management work, to improve availability of medical record by strengthening warehouse management from three aspects of filing, storage and lending. We adopted the following measures including establishing department filing rate reporting system, improving the medical record recovery monitoring system, to achieve the hospital medical record filing in time. Strengthening the management of medical record storage, improving the warehouse management system, set up medical record inspection team, to achieve medical record safe, orderly and scientific storage. Strengthening the management of medical record lending link, improve the system of medical record lending, establish selective examination system, to achieve ＂zero＂ loss of medical record in circulation. Using digital medical record management mode, scanning and bar code technology, can effectively keep the medical record availability.