新时期医院病案管理的方法与改进措施探析  

Methods and Improvement Measures of Hospital Medical Record Management in the New Era

作　　者：吴春华 WU Chunhua(Department of Medical Records,Xiamen Xianyue Hospital/Xianyue Hospital Affiliated With Xiamen Medical College/Fujian Psychiatric Center/Fujian Clinical Research Center for Mental Disorders,Xiamen Fujian 361000,China)

机构地区：[1]厦门市仙岳医院/厦门医学院附属仙岳医院/福建省精神医学中心/福建省精神疾病临床医学研究中心医务部病案室,福建厦门361000

出　　处：《中国卫生标准管理》2023年第23期1-4,共4页China Health Standard Management

摘　　要：患者病案管理具有一定的特殊性,并且在实际工作的过程中也存在一定的影响性;而在实际开展病案管理的过程中,现如今大部分的医院还存在一定的问题与障碍,这就造成病案管理过程中各种违规现象经常出现。医院病案保存着患者治疗的原因、经过、方式、最终结果,不仅在医学方面具有重要的参考作用,同时也能够成为患者后续治疗的关键档案。因此医院病案必须要得到管理与优化,这样才能够更好地发挥出病案这一特殊文本的作用。文章主要针对在新时期发展的过程中,医院病案管理的实际方案以及落实措施进行分析,希望可以起到参考的作用和指导临床实际工作的意义。The management of patients has its particularity and influence in the process of actual work,while in the process of carrying out the management of medical records,nowadays,most hospitals still have some problems and obstacles,which leads to various irregularities in the process of medical record management.The medical record of the hospital not only has the important reference function in the medical field,but also can become the key file of the follow-up treatment of the patients,therefore,the hospital medical record must be managed and optimized,so as to better play the role of this special text.In this paper,the development of the new period,the hospital medical record management of the actual program and implementation of measures for analysis,hoping to play a reference role and significance.

关 键 词：医院 病案 管理 病案利用 信息化 改进措施 

分 类 号：R197[医药卫生—卫生事业管理]