肿瘤专科医院门诊病案电子归档的应用  

Application of Electronic Archiving of Outpatient Medical Records in Cancer Hospital

作　　者：车轻轻 闫美玲[1] 季新强[1] 刘晶[1] Che Qingqing;Yan Meiling;Ji Xinqiang;Liu Jing(Key laboratory of Carcinogenesis and Translational Research(Ministry of Education/Beijing),Peking University Cancer Hospital&Institute,Beijing100142,China;不详)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所病案统计室、恶性肿瘤发病机制及转化研究教育部重点实验室,北京市100142

出　　处：《中国病案》2022年第12期1-3,共3页Chinese Medical Record

摘　　要：为了更好的适应新时代下病案管理工作,改进门诊数字化病案归档只能依靠单一纸质资料翻拍的归档模式,推动门诊病案电子归档是门诊病案无纸化管理的重要一步。门诊各项检验检查报告、电子病历记录等病案资料依靠有效的电子签名认证生成电子版病案资料,在数字化病案与传统纸质病案管理相结合的基础上,通过建立归档流程、规范归档方式、完善质检机制等措施,实现门诊病案电子归档。与门诊病案传统归档模式相比,电子归档在应用过程中,有效达到减少工作量、提升病案管理人员工作效率、节约纸质病案使用成本、提高患者复印病案满意度的目的,充分肯定门诊病案电子归档的必要性。但在实施过程中也存在一些问题,针对这些问题,需要通过加强保密意识宣教、做好权责划分、完善科室制度等措施进一步改进和完善门诊病案电子归档。In order to better adapt to the management of medical records in the new era and improve the archiving of outpatient digital medical records,we can only rely on the archiving mode of single paper data remake.Promoting the electronic archiving of outpatient medical records is an important step in the paperless management of outpatient medical records.Medical records such as outpatient inspection reports and electronic medical records rely on effective electronic signature authentication to generate electronic medical records.On the basis of the combination of digital medical records and traditional paper medical records management,the electronic archiving of outpatient medical records is realized by establishing archiving process,standardizing archiving methods,improving quality inspection mechanism and other measures.Compared with the traditional archiving mode of outpatient medical records,electronic archiving can effectively reduce the workload,improve the work efficiency of medical record managers,save the use cost of paper medical records and improve the satisfaction of patients with copying medical records,and fully affirm the necessity of electronic archiving of outpatient medical records.However,there are also some problems in the implementation process.In view of these problems,we need to further improve and improve the electronic archiving of outpatient medical records by strengthening the publicity and education of confidentiality awareness,dividing rights and responsibilities,and improving the department system.

关 键 词：病案管理 数字化病案 电子化归档 

分 类 号：R197.5[医药卫生—卫生事业管理]