摘要
植入性医疗器械相关病历资料是患者住院病案中的一项重要内容,相关科室有规范填写、粘贴及保存的职责。文章梳理了植入性医疗器械相关病历资料的管理要求,总结该院常见的病历书写、知情同意告知、条形码粘贴等问题及不利因素,提出针对性的改进措施,为本院植入性医疗器械相关病历资料的质量管理建立更加合理优化的模式。
The medical records related to implantable medical device are an important part of the patient's medical records,and relevant departments have the responsibility to fill in,paste and save them in a standardized manner.This article sorts out the management requirements of medical record data related to implantable medical devices,summarizes the common problems and adverse factors in medical record writing,informed consent notification,barcode pasting,etc.in this hospital,and proposes targeted improvement measures to establish a more reasonable and optimized mode for the quality management of medical record data related to implantable medical device in this hospital.
作者
张红亚
ZHANG Hong-ya(Department of Cancer Prevention,Fudan University Shanghai Cancer Center,Department of Oncology,Shanghai Medical College,Fudan University,Shanghai 200032)
出处
《中国医疗器械信息》
2022年第17期168-171,共4页
China Medical Device Information
关键词
植入性医疗器械
病历资料管理
措施
implantable medical device
medical records management
measures
