某院纸质病案管理与病案管理应用信息化流程改造实践  

Application of Information Process in Paper Medical Record Management and Electronic Medical Record Front Page in a Hospital

作　　者：张红亚 郑莹 张学云 莫淼[1] Zhang Hongya;Zheng Ying;Zhang Xueyun;Mo Miao(Department of Cancer Prevention,Fudan University Shanghai Cancer Center,Department of Oncology,Shanghai Medical College,Fudan University,Shanghai 200032,China;不详)

机构地区：[1]复旦大学附属肿瘤医院肿瘤预防部复旦大学上海医学院肿瘤学系,上海市200032

出　　处：《中国病案》2024年第2期1-3,共3页Chinese Medical Record

摘　　要：在互联网+医疗健康的背景下,医院更加注重信息化建设。某院病案室为了提升病案管理的信息化建设水平,集中梳理病案管理环节中效率低、质量差、流程冗杂等诸多问题,综合考虑各环节的交互关系,自2018年至2022年,针对性地运用病案数字化系统、微信复印预约快递小程序、病案签收示踪系统,对纸质病案进行优化处理,实现了简化流程并提高效率的效果,又开发出住院病案首页前置审核系统、住院病案首页编码数据预评估系统、院内ICD编码维护平台,对住院病案首页数据进行高质量管理。有规划地进行病案管理多环节信息化联合建设,多管齐下的信息系统建设使某院的病案管理流程变得更加高效、高质、便捷、现代化。In the context of Internet combined with medical health,hospitals pay more attention to information construction.In order to improve the information construction level of medical record management,the medical record room of a hospital focused on many problems such as low efficiency,poor quality,and miscellaneous processes in the medical record management link,comprehensively considered the interaction of all links,and targeted the use of medical record digitization system,Wechat copy reservation express program,medical record receipt and tracer system from 2018 to 2022.Optimized the treatment of paper medical records,realized the effect of simplifying the process and improving the efficiency,and developed the pre-review system of the front page of inpatient medical records,the pre-evaluation system of the coded data of the front page of inpatient medical records,and the hospital ICD coding maintenance platform to carry out high-quality management of the data of the front page of inpatient medical records.The multi-link information joint construction of medical record management is carried out in a planned way.The multi-pronged information system construction makes the medical record management process of a hospital more efficient,high-quality,convenient and modern.

关 键 词：纸质病案 住院病案首页 信息化 改造 

分 类 号：R197.323[医药卫生—卫生事业管理]