提质增效背景下的病理无纸化设计与实践  

The Design and Practice of Pathology Paperless Under the Background of Improving Quality and Efficiency

作　　者：李文桓 李维[1] 张晨[1] 朱声荣 武敏 计虹[1] LI Wen-huan;LI Wei;ZHANG Chen;ZHU Sheng-rong;WU Min;JI Hong(Information Managementand Big Data Center,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院信息管理与大数据中心,北京100191

出　　处：《医学信息》2023年第18期69-73,共5页Journal of Medical Information

摘　　要：随着医院电子病历系统的普及,医院对于病案精细化管理与病历安全有了更高的要求,病案无纸化管理成为病案精细化管理的重要手段。不同于其他常规的检查检验报告,病理检查报告在临床实际工作中存在大量出院后晚归的情况,使得其无纸化归档流程变得复杂。针对病理报告晚归问题,本研究梳理业务系统改造范围,设计病理晚归补充归档流程,建立医生-病理科-病案科三方协同的确认机制,以保障病理报告归档的完整性,最终实现病理报告的可信归档,提高了临床工作效率,确保病案安全。With the application of electronic medical record system in hospitals,higher requirements are placed on the delicacy management of medical records and the safety of medical records in hospitals.The paperless of medical records has become an important means of delicacy management of medical records.Different from other examination reports,a large number of pathological examination reports return after patients discharged in clinical practice,which makes the paperless archiving process complicated.Aiming at the problem of late returning pathological reports,this study analyzes the scope of the information system,designs the supplementary archiving process of late returning pathological reports,establishes the collaborative confirmation mechanism among doctors,pathology departments and medical records departments,so as to ensure the integrity of pathology reports archiving,and finally realize the reliable archiving of pathology reports,improves the efficiency of clinical work and ensures the safety of medical records.

关 键 词：病理报告 无纸化 补充归档 病理晚归 病案归档 

分 类 号：R197.3[医药卫生—卫生事业管理]