对三甲医院院内病案管理发展和机遇的探讨

Discussion on the Development and Opportunity of Medical Record Management in Tertiary A-level Hospitals

就诊病历上记录有患者的详细诊疗信息,包括既往病史、病程、诊断及治疗方案等,为保护患者的隐私,三甲医院要求病案管理相关工作的安全性也越来越高,鉴于此,管理院内病案达到安全有效的目的以及及时保存记录俨然已经成为医院院内病案管理工作的重点。病案管理工作是院内管理极为重要的一部分,其管理水平一般可以衡量医院的现代化建设状况。病案也见证了医院的整个发展历程,作为在临床中的基础资料发挥了巨大的实际参考价值,同时对医疗教学、医学证明、人事管理等众多工作环节产生了极为深远的影响。档案管理作为三甲医院院内管理的重要内容,在医院管理中占据着不可忽视的重要位置。而现今三甲医院院内档案管理仍存在管理人才短缺、缺少创新动力、管理体制落后、管理流程杂乱低效益等问题,文章对三甲医院院内病案管理工作现状及发展趋势和历史性机遇进行了较为深入的探讨。

The patient’s detailed diagnosis and treatment information is recorded on the medical record,including past medical history,course of disease,diagnosis and treatment plan.For the privacy of patients,the tertiary A-level hospitals require the safety of medical record management.In view of this,the management of hospital medical records to achieve the purpose of safety and effectiveness and the timely preservation of records have become the focus of hospital medical record management.Medical record management is a very important part of hospital management,and its management level can obviously reflect the modernization of the hospital.Medical records have also witnessed the development of the hospital,played a great practical reference value as the basic data in clinical practice,and had a far-reaching impact on many work links such as medical teaching,medical certification,personnel management and so on.As an important part of hospital management in tertiary A-level hospitals,archives management plays an important role in hospital management.At present,there are still some problems in the hospital archives management of the tertiary A-level hospital,such as the shortage of management talents,the lack of innovation power,the backward management system,the disordered management process and low efficiency.This article deeply discusses the current situation,development trend and historical opportunities of the hospital medical record management of tertiary hospital.