肿瘤专科医院门诊病案数字化的实施  

Effect of the Digital Implementation of Outpatient Cases in Specialized Tumor Hospitals

作　　者：闫美玲[1] 季新强[1] 王薇[1] 王小艺 刘晶[1] Yan Meiling;Ji Xinqiang;Wang Wei;Wang Xiaoyi;Liu Jing(Medical Record Statistics Department, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing 100142, China)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所病案统计室恶性肿瘤发病机制及转化研究教育部重点实验室,北京市100142

出　　处：《中国病案》2019年第4期6-8,共3页Chinese Medical Record

摘　　要：某肿瘤专科医院需要收集患者临床及用药信息,方便患者就诊而建立门诊病案。在病案管理过程中发现门诊病案面临库存空间不足、保管不当、工作效率低等问题。实施门诊数字化病案后,改变传统纸质病案的存储模式,减少纸质病案出库,提高工作效率和病案资料的安全性。通过对纸质病案的不足及数字化病案实施应用效果进行分析,从实践中总结经验,不断改进和优化新的门诊病案管理模式,利用先进科学的方法管理病案,顺应病案管理的发展趋势。The cancer specialist hospital needs to collect clinical and medication information for patients to facilitate patient visits and establish outpatient medical records. In the process of medical record management, it was found that the outpatient medical records faced problems such as insufficient inventory space, improper storage,and low work efficiency. After the implementation of outpatient digital medical records, the storage mode of traditional paper cases was changed, paper cases were reduced, and work efficiency and medical record data were improved. Through the analysis of the shortcomings of paper medical records and the application of digital medical records, the experience is summarized in practice, the new outpatient medical record management mode is continuously improved and optimized, and the advanced scientific methods are used to manage medical records and conform to the development trend of medical record management.

关 键 词：门诊病案 病案数字化 纸质病案 

分 类 号：R197.5[医药卫生—卫生事业管理]