病历档案的人文社会医学化构建探析  

Analysis on the Development of humanistic and social medical records

作　　者：徐欣云[1] 何小菁[2] Xu Xinyun;He Xiaojing(School of Historical Culture and Tourism,Jiangxi Normal University,Nanchang,Jiangxi 330027;School of Health Policy&Management,Nanjing Medical University,Nanjing,Jiangsu 211166)

机构地区：[1]江西师范大学历史文化与旅游学院,江西南昌330027 [2]南京医科大学医政学院,江苏南京211166

出　　处：《档案与建设》2024年第2期81-87,共7页Archives & Construction

基　　金：国家社科基金一般项目“‘中医针灸’非遗档案跨社群整合研究”(项目编号:22BTQ082)阶段性研究成果。

摘　　要：病历档案是医务人员诊治患者疾患的原始记录。现通行的病案只反映生物技术医学实践过程,缺少人文社会医学实践记录,客观上需要对现有病案进行重构。文章通过对我国传统医学病案和现代生物技术医学病案管理的溯源,证明构建人文社会医学病案的必要性,并指出人文社会医学病案应具有医乃仁术、以患者为先、为患者赋权、医患共济的特征,可通过补充人文病历、整合叙事病历、设计全新病案表单、采用智能病案等方式予以构建。The medical record archives is one of important specialized files.Currently,medical records only reflect the practical process of biotechnology medicine and lack records of humanistic and social medicine practice.Objectively,it is necessary to reconstruct existing medical records.The article traces the origins of traditional medicine and modern biotechnology medicine in China through medical record management,proving the necessity of developing medical records in humanistic medical records.The article analyzes the characteristics that should be possessed in the development of humanistic and social medical records,namely,these records shall be benevolent,patient-first,empowering patients,and showing doctorpatient cooperation.It proposes the feasibility of developing humanistic and social medical records,and constructs humanistic and social medical records by supplementing humanistic medical records,integrating narrative medical records,designing new medical record forms,and adopting intelligent medical records.

关 键 词：生物技术 医学 病案 人文社会医学 

分 类 号：G271[文化科学—档案学] R197.323[医药卫生—卫生事业管理]