病案数字化在病案管理中的应用评价  

Application evaluation on medical record digitization in medical record management

作　　者：宋琳琳 马文江[2] 王秋海[3] 叶鑫 李娜 柏媛 SONG Linlin;MA Wenjiang;WANG Qiuhai;YE Xin;LI Na;BAI yuan(Medical Record management Department,Tianjin Medical University Eye Hospital,Tianjin Medical University Eye Institute,Tianjin 300384,China;Medical Affair Department,Tianjin Medical University Eye Hospital,Tianjin Medical University Eye Institute,Tianjin 300384,China;Information Department,Tianjin Medical University School of Optometry and Ophthalmology,Tianjin 300384,China)

机构地区：[1]天津医科大学眼科医院、天津医科大学眼科研究所、天津医科大学眼视光学院病案管理科,天津300384 [2]天津医科大学医政科,天津300384 [3]天津医科大学信息科,天津300384

出　　处：《江苏卫生事业管理》2020年第7期927-929,共3页Jiangsu Health System Management

基　　金：天津医科大学医院管理创新项目基金(2017Y910)。

摘　　要：目的:评价病案数字化在病案管理中的应用效果。方法:运用病案数字化扫描技术,通过构建数字化硬件平台,关联病案首页信息,制作分类明细以及图像处理的方法,将纸质病案记录转化成“数字化病案”。进一步明确数字化标准,加强数字化工作人员的培训,建立病案领取——归还制度及三级质检反馈机制,从而增强病案数字化制作过程中各环节质量控制。结果:实施病案数字化管理后,提升了病案信息运用效能,实现实时在线调取查阅,节省60%的库房存储空间,增强了应对突发性危机的能力以及病案管理的安全性,病案复印效率显著提高,共享数字化病案大数据效果愈加明显。结论:病案数字化的应用为病案管理人员及医务人员临床、科研、教学等工作提供高效而便捷的服务,是病案有效管理的新模式。Objective:To investigate the effect of digitization of medical records in the management of medical records.Methods:With medical record digitization scanning technique,the paper medical records were converted into“digital medical record”through building a digital hardware platform,cataloguing by the first page of medical record,classifying by diseases and image processing meth⁃ods.The quality control in the process of digital medical record was enhanced to further clarify the digital standards,strengthen the training of digital staff,establish the medical record collection and return system and three-level quality control feedback mechanism.Results:The digital medical records could markedly improve the efficiency of the use of medical records information,achieve realtime online consulting,save 60%of the storage space in the warehouse,enhance the ability to deal with sudden incident crisis and the safety of medical records management.The copying efficiency of medical records significantly improved,and the sharing of digital med⁃ical records became more and more convenient.Conclusion:The application of digital medical record provides efficient and conve⁃nient service for medical treatment and clinical research,and is a new model of effective medical record management.

关 键 词：数字化病案 扫描技术 质量控制 病案管理 

分 类 号：R197.32[医药卫生—卫生事业管理]