医疗记录管理的信息化

Informationization of Medical Records Management

医疗记录,它客观、真实、完整和连续记录医生对病人疾病诊断、治疗,护理人员对病人的病情的观察、护理和医技部门的检验结果。它对于患者、医院、医疗保险对有着至关重要的作用。医疗记录管理实现信息化,医疗机构的信息普及率将逐步提高。这是提高医疗机构水平和实施管理效率的重要措施,同时将减少医患纠纷的发生几率,使医生、病人的合法权益都将得到保障。

Medical records, which objectively, truthfully, completely, and continuously record the doctor＇s diagnosis and treatment of the patient＇s disease, the caregiver＇s observation of the patient＇s condition, and the results of the examinations of the nursing and medical technology departments. It plays a crucial role for patients, hospitals, and health insurance. The management of medical records will be informatized, and the information penetration rate of medical institutions will gradually increase. This is an important measure to improve the level of medical institutions and the implementation of management efficiency. At the same time, it will reduce the occurrence of disputes between doctors and patients, so that the legitimate rights of doctors and patients will be protected.