新时代现代病案管理实践与思考

Modern medical record management in the new era

目的总结某医院在现代病案管理工作中的重要实践方法,思考现代病案管理的发展方向,为各医院提高管理工作效率,顺应时代发展创新工作提供思路。方法以病案首页质量精细化管理为抓手,从规范院内术语、开发信息系统及持续改进填写质量3大方面推进医院在提高首页填报质量方面的相关工作。结果通过不断思考与改进工作方法,该院病案首页质量持续提升,长期以满分名列全省第一。结论病案管理正经历一场纸质病案与电子病历并存、由病案保管向病案利用的重大变革,完善管理机制、建立人才梯队及加强信息化建设等方法是提高首页数据质量,应对变革的有效措施。

Objective To summarize important practical methods and think about the development direction of modern medical record management in a hospital so as to provide ideas for hospitals to improve the management efficiency and comply with development and innovation of the times.Methods Taking the fine quality management of the first page of medical records as the main point,the hospital advanced related works in improving the first page filling quality from three aspects:standardizing inner-hospital terminology,developing information systems,and continuously improving the filling quality.Results Through continuous thinking and improvement of working methods,the quality of the first page of medical records in the hospital was steadily improved,and was ranked first in the province with full marks for a long time.Conclusion Medical record management is undergoing a significant change where paper medical records and electronic medical records coexist,and medical record storage shift to medical record utilization.Therefore,such measures as improving management mechanism,building up talent team,and strengthening information construction are effective for improving the data quality of the first page of medical records and responding to the reforms.