纸质病案数字化的实践效果  

The Practice Effect of Paper Medical Records Digitization

作　　者：黄田镔[1] 吴朝晖[1] 

机构地区：[1]福建中医药大学附属泉州市正骨医院,泉州市362000

出　　处：《中国病案》2016年第3期51-52,65,共3页Chinese Medical Record

摘　　要：介绍病案数字化工作展开的步骤,病案数字化使得复印工作更加高效、快捷、准确,提高患者对复印的满意度;实现病案资源共享,方便医护人员对病案的利用;更利于病案的长期保存,节约病案的存储空间。但是在病案数字化工作中存在纸质病案打印效果不理想和化验单黏贴不满意,数字化翻拍人员因素质问题而导致翻拍效果不佳和项目错乱,数字化质量控制体系不全导致监管不利等问题。针对以上问题应采取了以下措施:积极与临床科室、检验科、信息科沟通合作;规范化验单黏贴;加强对翻拍人员的技术培训与病案信息学常识培训,加强保护病人隐私意识;专人监管;建立健全的数字化工作监管体系。This article introduced the development steps of medical records digitization, which make the duplication work of medical records more effective, convenient and accurate, improve the satisfaction rate of patients, convenient for the utilization of medical records for doctors and nurses, and beneficial to long term storage of medical records and save memory space. But many problems occur in the work of medical records digitization, such as unsatisfactory print results and laboratory sheet of paper medical records, bad copying effect and mistaken items because of the quality problems of the digitization copy staff as well as failure supervision caused by incomplete quality control system of digitization. We took below measures aimed at the above problems such as to communicate and cooperate with clinical departments, laboratory department and information department positively, standardize the paste of laboratory sheet, strengthen technology training of the copy staff as well as medical records information knowledge training, strengthen awareness of protecting the privacy of patients, set specially-assigned person for supervision and establish complete digitization work supervision system.

关 键 词：病案数字化 病案管理 翻拍技术 

分 类 号：R197.323[医药卫生—卫生事业管理]