多院区一体化管理的病案归档与复印探讨

Discussion on Filing and Copying of Medical Records in Integrated Management of Multi Hospital

某院传统病案归档采用系列编号模式上架与存储,病案复印仅能提供现场登记直提或邮寄2种方式。随着某院多院区诊疗的开展,对病案的归档与复印提出了更高的要求。分析某院传统单院区住院病案归档复印服务流程的弊端,根据国家病案管理的要求以及多院区的特点,制定适应多院区病案归档复印的优化方案:将归档中的系列编号模式改变成单一病案编号,编号上方增加区分院区与年限的条形码流水编号,用SQL的自定义函数将2个号关联,便于上架与查找。病案袋下角增加红绿2色色标,便于总库房划分区域归档。同时借力信息技术,通过CA认证实现电子签名与电子病历复印的直接打印,增加微信小程序的病案预约、登记、复印和邮寄功能,通过扫描传输开展了跨院区非现场复印模式。各项精细化管理措施于2022年逐步得以实现,不仅方便患者,也提升医院病案管理质量与综合服务能力。

Traditional medical records of a hospital were archived and stored in serial numbering mode.Medical records could only be copied by on-site registration and direct pick-up or mail.With the development of multi-hospital diagnosis and treatment in the hospital,higher requirements were put forward for the filing and copying of medical records.This study analyzes the disadvantages of the filing and copying service process of inpatient medical records in a single hospital area.According to the requirements of national medical record management and the characteristics of multi-hospital districts,an optimized plan for filing and copying medical records in multi-hospital districts was formulated:the serial numbering scheme in the archive was changed to single case numbers.A barcode serial number was added to distinguish the hospital area and the year above the number,and the custom function of SQL was used to associate the two numbers,which was convenient for listing and searching.Red and green color codes were added to the lower corner of the medical record bag to facilitate the division of the general warehouse for filing.At the same time,with the help of information technology,the direct printing of electronic signatures and copies of electronic medical records was realized through CA certification.The functions of medical record appointment,registration,copying and mailing had been added to the WeChat applet,and the cross-campus off-site copying mode had been carried out through scanning and transmission.Various refined management measures were gradually realized in 2022,which was not only convenient for patients,but also improved the quality of hospital medical record management and comprehensive service capabilities.