新型冠状病毒肺炎住院病案管理探讨

Discussion on Management of COVID-19 Inpatient Medical Records

根据新型冠状病毒的流行病学特点,探讨新型冠状病毒肺炎患者病案无纸化模式下病案管理流程、电子签名的法律地位及可靠电子签名需具备的条件、临床数据中心建设对无纸化下保证信息获取全面的意义、电子归档的必要性和归档的步骤。纸质病案管理模式下污染区和清洁区纸质病案的种类、实行新冠患者住院病案一人一袋管理方法中污染区纸质病案送往清洁区和直接送往病案室污染区流程、清洁区病案送往污染区的流程,并根据新冠病毒的特点及纸质病案的特性提出采用56℃30分钟进行纸质病案消毒和75%酒精或过氧乙酸进行密封袋表面消毒方法和流程;病案科分为污染通道和清洁通道管理、每个通道的功能和消毒方法,病案科清洁区和污染区人员防护等级和方法。

According to the epidemiological characteristics of novel coronavirus,this paper discusses the medical record management process of COVID-19 patients under paperless medical record mode,the legal status of electronic signature and the necessary conditions for reliable electronic signature,the significance of the construction of clinical data center to ensure the comprehensive information acquisition under paperless medical record mode,the necessity of electronic archiving and the steps of archiving.Paper-based medical records management mode pollution area and clean area the kinds of paper-based medical records,the new crown in-hospital medical record one bag of management method of the pollution zone papery medical records sent to the clean area and directly to the record room pollution area process,the clean area medical records sent to the process of pollution area,and according to the will of coronavirus features and characteristics of the paper-based medical records and put forward using paper-based medical records of 56℃ for 30 minutes for disinfection and 75% alcohol or peracetic acid sealing bag surface disinfection methods and processes;The medical record department is divided into the management of contaminated channels and clean channels,the functions and disinfection methods of each channel,and the protection levels and methods of personnel in the clean and contaminated areas of the medical record department.