探讨电子病案归档系统在病案管理工作中的应用  

Discussion on Application of Electronic Medical Record Filing System in Medical Record Management

作　　者：郭慧玲[1] 温星来 Guo Huiling;Wen Xinglai(Department of Medical Record&Statistics,The Sixth Affiliated Hospital of Guangzhou Medical University,Qingyuan People’s Hospital,Qingyuan 511518,Guangdong Province,China)

机构地区：[1]广州医科大学附属第六医院,清远市人民医院病案统计室,广东省清远市511518

出　　处：《中国病案》2020年第10期3-5,共3页Chinese Medical Record

摘　　要：某院从医患签名的数字认证、归档项目的分类、扫描程序的开发、功能模块的建设四个方面完成了电子病案归档系统的建设。电子病案归档系统的引进,改变了传统纸质病案管理的工作模式,简化了病案整理、借阅、复印等流程。通过探讨某院电子病案归档系统应用过程中存在的问题,对问题分析核查、使用专柜保存、规范医师操作、优化归档流程等方法进行改进和完善,在挑战中谋求发展,在发展中积累经验,不断改进和完善电子病案归档系统在病案管理工作中的应用。A hospital has completed the construction of electronic medical record filing system from four aspects:digital authentication of doctor-patient signature,sorting and classification of archiving projects,development of scanning program,and construction of functional modules.The introduction of electronic medical record filing system has changed the working mode of traditional paper medical record management and simplified the process of sorting,borrowing and copying medical records,which has brought both convenience and challenge.The electronic medical record filing system is still in its initial stage,and there are still some problems,such as the wrong archiving items,the disordered storage of the remaining paper medical records,the untimely writing of medical records,and the delay of quality control and repair.The purpose of this paper is to explore a hospital electronic medical record filing system problems existing in the application process,analyze the causes,and on these problems timely verification,use counters save save method,standard operation doctor,optimization of filing process to improve and perfect,seek development in the challenge,accumulate experience in the development,constantly improve and perfect the electronic medical record filing system in the application of the medical record management.

关 键 词：电子病案归档系统 病案管理 问题 改进 

分 类 号：R197.323[医药卫生—卫生事业管理]