入出院日报表与病历回收管理的研发及应用

Discharged into the Daily Report and Medical Records Management Recovery Development and Application

目的充分利用医院信息系统的资源,杜绝入出院日报表的差错现象,保障医院病案回收和统计工作的准确性,减轻病案管理人员的工作量。方法病案管理系统与医院HIS系统、住院电子病历系统信息相关联,住院日报表自动生成,病案回收人员将回收病历首页的住院号用扫描方式,自动生成归档病历记录。结果每月可节约一个病案录入人员9 d的出入院日报表的录入、修改工作时间,住院日报准确率由95%左右提高到100%,病案的安全得到保证。结论为病案管理人员的病历回收、录入工作提供了方便、准确的信息,进一步提高了工作效率,减轻了工作人员的工作负担;有利于医务工作人员及时书写,保证了诊治记录的完整性,相应地提高了病案的质量,从而有效地避免和减少医疗纠纷事件的发生。

Objective To make full use of the resources of the hospital information system, to eliminate the phenomenon of error discharged into daily report, and ensure the accuracy of the Medical Record recycling and statistical work, reduce the workload of case management staff. Methods The medical records management systems and hospital HIS system, hospital electronic medical records system information associated hospitalization Automatic report generation, case recyclers recovered inpatient medical home number with scanning, automatic generation of archive medical records. Results The monthly savings of a medical record entry staff nine days of the date of admission of the report entry, modify working hours, daily hospitalization accurate rate of about 95% to 100%, case of safety is guaranteed. Conclusion The medical case management staff to the recovery of entry work provides a convenient, accurate information to further improve the work efficiency, reduce the workload of staff; conducive to timely medical staff to write, to ensure the integrity of diagnosis and treatment records,corresponding increase in the quality of medical records, so as to effectively prevent and reduce incidents of medical malpractice.