现代化信息技术在病案管理中的应用  

Application of Modern information Technology in the Management of Medical Records

作　　者：赖丽文[1] 王逸纯 赵淑媛[1] 

机构地区：[1]广东省医学科学院 广东省人民医院病案科

出　　处：《中国病案》2014年第4期34-36,共3页Chinese Medical Record

摘　　要：利用现代化信息技术,优化整合医院信息系统,改变传统病案管理模式,将信息化技术应用于病案管理工作中。取消了病案科对病案首页信息的手工录入,大部分信息通过系统获取;取消"叠瓦"式张贴检验报告单;数字化病案运用,优化查询与借阅方式,取消纸质病案借阅;缩微病案有效缩减大面积库房;实现出院诊断与手术操作在线编码;建立全程质控体系,加强了在线病历环节监控力度。现代化信息技术在病案管理中的应用,有效地节省人力资源;减少病案库房空间从而增加医疗用房;更有效地提高病案管理工作效率和管理质量,信息利用更加便捷。We use modern information technology, optimize the integration of hospital information system, change the traditional medical record management mode to management medical records. After the reform, the majority of information in the frontsheet of medical records was acquired through the retrieval system. The ＂imbricated＂ paste inspection report was cancelled, and medical records were digitalized. Lending and inquiry processes were optimized, and the lending of paper medical records was abolished. Miniature medical record effectively reduce large warehouses. The encoding of the discharge diagnosis and surgery operation is online.The whole quality control system is established, and the online medical records link monitoring is strengthened. Modern information technology in the application of the medical record management can Effectively save the human resources. Reduce medical record storage space so as to increase the medical room. More effectively improve medical record management work efficiency and the quality of management, and the information usin~ more convenient.

关 键 词：信息技术 病案管理 应用 

分 类 号：R197.323.1[医药卫生—卫生事业管理]