互联网诊疗中病案管理制度的建立

Thoughts on the Establishment of Medical Record Management System in Internet Medical Treatment

互联网诊疗开展已日益普及,其在带来诸多便利的同时对病案管理提出了新挑战。通过对病案管理政策演进及发展情况进行梳理,比较互联网诊疗与传统线下诊疗在人员特征、服务形式、病案内容、归档应用、信息安全等多个维度的异同点,分析当前互联网诊疗病案管理在规范标准、应用实施等方面存在的不足。进一步结合医疗质量核心制度中的病案管理制度,建议设立准入规范、扩充病案内容形式、更新质控标准和措施,同时重点强化隐私保护。

The development of Internet medical has become more and more popular,which brings new challenges to medical record management while bringing many conveniences.By sorting out the evolution and development of medical record management policies,comparing the similarities and differences between Internet medical and the traditional one in terms of personnel characteristics,service forms,content,archiving applications,and information security,this article analyzes the shortcomings of current Internet medical record management in standardization and implementation.Further combining with the medical record management system in the core medical quality system,it is suggested to set up access standards,expand the contents and forms of medical records,update the quality control standards and measures,and strengthen the protection of privacy.