某院病案无纸化管理实践

Practice of paperless management of medical records in a hospital

病案无纸化管理对推动医院精细化管理具有重要意义,在国家政策和医疗机构信息化发展的双重驱动下,无纸化病案成为病案发展的必然趋势。然而,现阶段我国仍存在大量无法电子化或不能直接上传医院电子病历系统的病历资料。浙江省嘉兴市第一医院自2019年启动病案无纸化建设项目,搭建了病案无纸化管理系统,形成了对病案采集、病案归档、病案存储、病案管理和利用的全流程闭环管理体系,至2021年底实现了所有科室的病案无纸化归档,全面实现了电子签名,并实现了单机版设备报告、高值耗材条形码、手术麻醉相关文书及外送检验报告等的无纸化,无纸化率达到98.5%。通过病案无纸化管理,强化了对病案质量和医疗质量的监管,降低了营运成本并提高了工作效率,为医务人员查阅病案信息及数据应用提供了便利,切实提高了医院的精细化管理水平,可为其他医疗机构的病案无纸化管理提供参考。

Paperless management of medical records is of great significance in promoting refined hospital management.Driven by national policies and the development of information technology in medical institutions,paperless medical records have become an inevitable trend in the development of medical records.However,at present,there were still a large number of medical record data in China that cannot be digitized or directly uploaded to hospital electronic medical record systems.Since 2019,the First Hospital of Jiaxing has launched a paperless medical record construction project and established a paperless medical record management system,forming a closed-loop management system for the entire process of medical record collection,archiving,storage,management,and utilization.By the end of 2021,paperless of medical records in all departments had been achieved,electronic signatures had been fully implemented,and paperless versions of reports of standalone equipment,high-value consumables barcodes,surgical anesthesia related documents,and outsourced inspection reports had been achieved,with a paperless rate of 98.5%.Through paperless management of medical records,the supervision of medical record quality and medical quality has been strengthened,operating costs have been reduced and work efficiency has been improved.At the same time,this has provided convenience for medical personnel to access medical record information and applicate of the data,and has effectively improved the hospital′s level of refined management.It can provide reference for paperless management of medical records in other medical institutions.