信息化背景下病历档案管理

随着信息和大数据在各行各业快速发展,医院病历档案数字化、网络化已经成为档案管理的一项重要研究内容。电子病历具有准确、共享、高效的优越性,也同时存在着病历质量、个人隐私、信息安全等方面问题,需要进一步改进和完善。尤其在疫情防控常态化情形下,电子化的病历档案除具备传统病历功能外,还承载着保障防控安全、提升诊疗质量、规范医疗行为,提高医院整体管理水平的作用。

With the rapid development of information and big data in all walks of life,the digitization and networking of hospital medical record archives has become an important research content in archive management.Electronic medical records have the advantages of accuracy,sharing and high efficiency,but there are also problems in the quality of medical records,personal privacy,and information security,which need to be further improved and perfected.Especially in the case of normalization of epidemic prevention and control,in addition to the traditional medical record functions,electronic medical record archives also carry the role of ensuring the safety of prevention and control,improving the quality of diagnosis and treatment,standardizing medical behavior,and improving the overall management level of the hospital.