新形势下医院病案管理面临的问题与挑战

Problems and Challenges in Hospital Medical Records Management under the New Situations

阐述《医疗机构病历管理规定(2013年版)的特点,提出当前医院病案管理发展面临的挑战,针对医改的契机,电子病历使用范围不断扩大,医院病案管理工作应加强管理职能、强化服务意识、提高服务水平、加强编码人才培养、完善病案质控体系、用现代技术解决历史病案存储利用、电子病历建设等问题。

The paper analyzed the features of ＂The Regulations of Medical Records in Medical Institutions （2013 E- dition） ＂ and proposed current challenges in the development of hospital medical records management. Based on the ongoing heahhcare reform, the scope of application of electronic medical records was increasingly expanding. Medical records manage- ment required us to strengthen the function of management, enhance service awareness and level, train more coding talents, perfect the quality control system of medical records, and deal with problems such as history medical records storage and utili- zation, and the establishment of electronic medical records by modem technology.