新型冠状病毒肺炎期间的病案管理流程  

Medical Record Management Process of the Inpatients with COVID-19

作　　者：何艺 李迪[2] 吴剑宏[1] 杨奇盛[3] 葛名欢[4] 王雷[5] 张雪梅 裴圣广[5] 王萍[1] 高红[1] 夏海朋 裴益 牟岚[1] He Yi;Li Di;Wu Jianhong;Yang Qisheng;Ge Minghuan;Wang Lei;Zhang Xuemei;Pei Shengguang;Wang Ping;Gao Hong;Xia Haipeng;Pei Yi;Mu Lan(Tongji Hospital Affiliated to Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,Hubei Province,China;不详)

机构地区：[1]华中科技大学同济医学院附属同济医院,武汉市430030 [2]华中科技大学同济医学院附属协和医院病案统计科,武汉市4300223 [3]武汉大学中南医院病案室,武汉市430071 [4]武汉大学人民医院,武汉市430060 [5]华中科技大学同济医学院附属武汉中心医院,430014 [6]中国人民解放军中部战区总医院,武汉市430010

出　　处：《中国病案》2020年第10期1-3,共3页Chinese Medical Record

摘　　要：本文根据流行性传染病的特点,制定了新型冠状病毒肺炎期间的病案管理流程:将电子病历的打印时间延后,打印地点调整为病案科的清洁区域,对特殊纸质病历的保管和消毒流程进行了规范,以降低纸质病案的污染风险;线上办理病案复印和电子版病案复制件的运用,以消除传统病案复印环节人群聚集的感染风险;对特殊纸质病历和电子病历的三种归档方式进行比较后发现,无纸化病案管理流程是疫期阻断病案纸张的病原传播途径、降低医院感染风险的最佳方案。According to the characteristics of epidemic diseases,this paper developed the medical records management process of inpatient with COVID-19:changing the time and space node of electronic medical record printing,and standardizing the operation,storage and disinfection process of paper medical record,so as to reduce the pollution risk of paper medical record.The application of online copying and electronic copying of medical records eliminates the risk of infection caused by the crowd gathering in the traditional copying of medical records.Through a further comparison of the three ways of filing electronic medical records,it is found that the paperless medical records management process is the best way to block the pathogen transmission route of medical records during the epidemic period and reduce the risk of nosocomial infection.

关 键 词：新型冠状病毒 病案管理 流程 

分 类 号：R197.323[医药卫生—卫生事业管理]