病历无纸化档案管理系统在医院工作中的实践探讨

Discussion on the Practice of the Paperless Archives Management System of Medical Records in the Hospital Work

医疗体制大数据时代的来临,促使智慧型医院得到迅速发展,病历的档案信息化建设是医院信息化的重要组成部分,医院的管理想要融入医院信息化大潮,必须打破传统管理模式,创建信息化条件下新的管理模式。淄博市市立医院顺应时代发展,全面实现电子病历无纸化档案管理。该文通过电子病历各系统的集成归档过程、电子病历的储存复印、质控、检索应用、数据共享及应用于医院管理方面进行了阐述,医院的档案资源在无纸化系统的推动下,得到了更好的发挥和利用。并对在实施过程中的安全问题、使用权限、患者隐私等方面做了论述,提出了能够完善此项工作的有效途径,在无纸化基础上的病历档案管理对推动医院数字化管理上效果显著,具有一定的可行性,值得推广和应用。

The advent of the era of big data in the medical system has promoted the rapid development of smart hospitals.The informatization of medical records is an important part of hospital informatization.To integrate hospital management into the tide of hospital informatization,the traditional management model must be broken;to create a new management model under the conditions of informatization.Zibo Municipal Hospital is in line with the development of the times and fully realizes the paperless file management of electronic medical records.This article uses the integrated archiving process of the electronic medical records systems,the storage and copying of electronic medical records,quality control,retrieval applications,data sharing and application in hospital management.It is stated that the archive resources of the hospital have been better utilized under the impetus of the paperless system.It also discusses the security issues,usage rights,patient privacy and other aspects in the implementation process,and puts forward an effective way to improve this work.The management of medical records based on paperless has a significant effect on promoting the digital management of hospitals,which has a certain feasibility,is worthy of promotion and application.