基于互联网诊疗流程的病案管理工作探讨

Discussion on Medical Record Management Based on Internet Medical Process

互联网诊疗病历记录互联网诊疗信息,因其具有收集范围广、形式多样、共享性强等不同于传统病历的特点,对其进行管理的重要性和难度日益增强。本文对贯穿互联网诊疗全流程的病案管理要点进行阐述分析,包括患方和医生端书写模板制定、患方上传图片审核、医生病历调阅管理、规范互联网用语、线上病历归档、诊疗疾病编码、病历质量管理等。遵循线下病历管理规范,创新线上病历管理理念,探索具有互联网诊疗特色的病案管理方法。

Internet Medical Record recorded the internet medical process.Different from traditional medical records,Internet Medical Record has the characteristics of wide range of collection,diversified forms,and strong sharing characteristics.This article analyzed the main points of internet medical record management throughout the entire internet medical process,including the formulation of patient and doctorside writing templates,the review of pictures uploaded by patients,the management of doctors'medical records,the standardization of Internet terms,online medical records archiving,diagnosis coding,and the quality management of medical records.By following the offline medical record management norms and innovating the concept of online medical record management,this article explores the internet medical record management methods.