对辅助生殖技术专科病案管理现状的探讨

Discussion on the Current Situation of Medical Record Management of Assisted Reproductive Technology

目的:通过对辅助生殖技术病案管理的现状进行探讨,为改善目前辅助生殖技术专科病案的管理模式,从而提高辅助生殖技术病案为临床、教学、科研的服务能力提供意见参考。方法:通过文献分析法以及结合日常工作经验和体会,对辅助生殖技术病案管理目前存在的特点难点进行分析,提出改进的建议和对策。结果:目前我国辅助生殖技术病案管理普遍存在治疗流程复杂、连续性强、随访周期长、病历完善时间长、病历质量控制难等特点,专业人员的缺乏以及对病案管理的认识偏差等难点。总结和建议:规范流程、细化管理、建立质控体系、加强信息化管理、增加专业人员、加强结构化电子病历管理,提高病历对临床的服务能力。

Objective: By discussing the current situation of assisted reproductive technology medical record management, so as to improve the current management mode of assisted reproductive technology medical record, so as to provide advice and reference for improving the medical record of assisted reproductive technology for clinical, teaching and scientific research. Methods: Through literature analysis and combined with daily work and experience, the characteristics and difficulties existing in the management of assisted reproductive technology medical record were analyzed, and suggestions and countermeasures for improvement were put forward. Results: At present, the medical record management of assisted reproductive technology in China is characterized by complicated treatment process, strong continuity, long follow-up period, long improvement time of medical record, difficult quality control of medical record, lack of professionals and deviation of understanding of medical record management. Conclusion and suggestions: standardize process, refine management, establish quality control system, strengthen information management, increase professionals, strengthen structured electronic medical record management, and improve the clinical service ability of medical records.