病案管理的信息化特征与风险防范  

Informationalized characteristics of medical records management and risk prevention

作　　者：申萍[1] 胡新勇[2] 张曙光[3] 杜德洁[1] 

机构地区：[1]南京军区南京总医院质量管理科,江苏南京210002 [2]南京军区南京总医院院部,江苏南京210002 [3]南京军区南京总医院信息科,江苏南京210002

出　　处：《医学研究生学报》2009年第10期1081-1083,共3页Journal of Medical Postgraduates

摘　　要：随着医院病案现代化建设和信息化战略的规划实施,病案管理已经过渡到病案资源电子化、数字化的信息化管理阶段,病案管理的信息化特征也越加明显,一是病案信息的集成和存储需要信息技术做支撑,二是病案利用的社会化需要互联网技术做平台,三是病案资源的开发利用需要先进的数据仓库和数据挖掘技术做保证,同时,病案信息化管理存在着人为的泄密风险、完整性受损的风险、可抵赖性风险,以及信息系统的安全风险。针对存在的风险采取相应的防范措施,规范病案的信息化管理流程,完善其管理制度和法律规定,将是质量管理者的一项长期而艰巨的任务。With the modernization of the medical records and the planning implementation of informationalized strategy,the management of medical records has been extended to the stage of supervising resources electronic and digital,also the informationalized features is more evident.one reason is the integration and storage of medical records information need informationalized technology support,and the other is the socialization of utilizing medical records needs the internet technology as platform,and the third is the exploration and utilization of resources in medical records requires advanced data warehouse and data mining technology as guaranty,at the same time,the management of medical records information have the man-made risk of divulging secrets,the risk of damage to the integrity,the risk may be to deny the fact,as well as the risk of information systems security.The corresponding preventive measures taken to standardize the medical records management processes,improve its management system and the law,will be a long-term and arduous task to the quality manager.

关 键 词：病案管理 信息化 风险防范 

分 类 号：R197.323[医药卫生—卫生事业管理]