区县级医院病案管理工作的标准化建设

Standardization of Medical Record Management in District and County Hospitals

随着我国医疗改革的深入,基本医疗保险、商业保险在我国的开展,病案资料在医院医疗、教学、科研、医疗付款凭据和医疗法律凭证方面发挥着具大的作用。病案管理工作及流程的规范化直接影响到国家公立医院绩效考核及医保分值付费工作。本文通过对某院病案工作中的回收、加工、服务等方面的规范化管理进行阐述,积极有效地提高病案管理的标准化建设。

With the deepening of China’s medical reform and the development of basic medical insurance and commercial insurance in China, medical records play a greater role in hospital medical treatment, teaching, scientific research, medical payment voucher and medical legal voucher. The standardization of medical record management work and process has a direct impact on the national public hospital performance appraisal and medical insurance score payment work. This paper expounds on the standardized management of recovery, processing and service in the medical record work of a hospital, so as to actively and effectively improve the standardization of medical record management.