无纸化管理系统在病案工作中的应用  

Application of Paperless Management System in Medical Record Work

作　　者：左海霞[1] Zuo Haixia(Department of Medical Record Management,Linzi District People's Hospital,Ziho 255400,Shandong Province,China)

机构地区：[1]山东省淄博市临淄区人民医院病案管理科,山东省淄博市255400

出　　处：《中国病案》2020年第7期6-8,共3页Chinese Medical Record

摘　　要：通过研究电子病历无纸化的建设归档过程,无纸化病案管理系统在病案储存、病历资料复印、病案质量监控、国际疾病分类工作中的应用,寻找解决策略,使无纸化病案能够安全有效的开展和实施。无纸化管理系统改变了传统的病案管理模式,实现电子病历的归档储存、电子病历复制复印等工作,节省了人力物力。并优化了电子病历的在线检索、实时查阅工作流程,提高了病案工作效率。在使用的过程中,针对电子病历的延迟回收、系统归档不全、隐私保护、系统权限等问题进行不断完善,通过不断地实践和摸索,逐渐将无纸化管理系统完善。This paper describes the paperless construction and filing process of electronic medical record, studies the application of paperless medical record management system in medical record storage and copying, medical record quality control, as well as in disease coding and solutions. It is proved that our hospital can carry out the implementation safely and effectively. Paperless management system has changed the traditional medical record management mode, realized the filing and storage of electronic medical record, copying and copying of electronic medical record, and saved human and material resources. And optimize the online retrieval of electronic medical records, always look up the workflow, improve the efficiency of medical records. In the process of using, for the delayed recovery of electronic medical records, incomplete system archiving, privacy protection, system permissions and other issues. This paper has carried on the effective way to perfect this work, and needs to gradually perfect the system through continuous practice and exploration.

关 键 词：电子病历 无纸化 病案 管理 

分 类 号：R197.323[医药卫生—卫生事业管理]