新形势下医院病案管理工作的分析与研究  

Analysis and Research on the Management of Hospital Medical Records under the New Situation

作　　者：余意玉[1] 黄瑞妍[2] 李晓艺[2] 伍津[3] 刘金蓉 YU Yiyu;HUANG Ruiyan;LI Xiaoyi;WU Jin;LIU Jinrong(Medical Department,Guangdong Provincial Institute of Occupational Disease Prevention,Guangzhou,Guangdong Province,510300 China;Office of Guangdong Provincial Occupational Disease Prevention and Control Institute,Guangzhou,Guangdong Province,510300 China;Science and Education Section,Guangdong Occupational Disease Prevention and Control Institute,Guangzhou,Guangdong Province,510300 China)

机构地区：[1]广东省职业病防治院医务科,广东广州510300 [2]广东省职业病防治院院办公室,广东广州510300 [3]广东省职业病防治院科教科,广东广州510300

出　　处：《中国卫生产业》2021年第32期63-66,共4页China Health Industry

基　　金：广东省职业病防治重点实验室(2017B030314152);广东省医学科研基金(C2021019)。

摘　　要：病案是患者在医疗机构诊疗、实验室检查及记录转归的重要信息记录,具有重要的保存价值,不仅可以为疾病诊疗、监测提供具体数据,而且在发生医患纠纷时也可提供切实的参考数据,因而病案具有重要参考价值和法律效应,必须积极提升其管理质量。职业病防控是我国公共卫生工作的重点,对于职业病患者的病理管理也必须紧跟新形势,改进和优化病案管理方式、方法,进而促进职业病防治工作实现可持续发展。该文针对性新形势下医院病案管理工作进行综述研究。Medical records are important information records for patients in medical institutions for diagnosis and treatment,laboratory examinations and records of outcomes,and have important preservation value.It can not only provide specific data for disease diagnosis and treatment and monitoring,but also provide practical reference data in the event of doctor-patient disputes.Therefore,medical records have important reference value and legal effect,and the quality of their management must be actively improved.Occupational disease prevention and control is the focus of my country's public health work.The pathological management of occupational disease patients must also keep up with the new situation,and improve and optimize the management methods and methods of medical records.In order to promote the sustainable development of occupational disease prevention and control.The paper conducts a review and research on the management of hospital medical records under the new situation.

关 键 词：医院 病案管理 职业病 疾病监测 信息化 

分 类 号：G271[文化科学—档案学]