基层病案信息管理现状及发展对策探讨  

Discussion on the Current Situation and Development Countermeasures of Basic Medical Record Information Management

作　　者：尹旋旋 冀国霞 袁芳 Yin Xuanxuan;Ji Guoxia;Yuan Fang(Qingzhou City Center for Disease Control and Prevention,Qingzhou 262500,Shandong Province,China;不详)

机构地区：[1]青州市疾病预防控制中心,山东省青州市262500

出　　处：《中国病案》2024年第5期4-5,103,共3页Chinese Medical Record

摘　　要：社区卫生服务机构作为我国的基层卫生服务机构,其产生的病案信息经分析、汇总形成数据库,对相关部门了解居民健康状况和健康需求,对国家制定、调整卫生政策及社区卫生服务发展规划具有参考意义。在实际工作中,对病案管理工作缺乏重视是影响基层病案发展的首要因素,专业技术人才缺乏、从业人员缺乏系统性培训制约了基层病案发展,缺乏统一的病案质量执行标准造成基层病案质量不规范、不统一,数字化技术应用不足阻碍了基层病案信息化进程。应从提高对基层病案信息管理工作重要性认识、加强人才队伍培养与规范化培训、推进电子病案系统融合及质量控制体系建设、在应用中提高电子病案的普及和管理水平、推动实现医联体内部电子病案共享互认5个方面入手推进基层病案信息发展,为改进我国基层病案信息管理工作提供借鉴。Community health service institutions,as the primary health service institutions in China,analyze and summarize the medical record information generated in the process of their work to form a database,which is of reference significance for relevant departments to understand the health status of residents and analyze their health needs,and for the country to formulate and adjust health policies and community health service development planning.In actual work,the lack of attention to medical record management is the primary factor affecting the development of grassroots medical records.The lack of talents and the lack of systematic training for practitioners have restricted the development of grassroots medical records.The lack of unified implementation standards for medical record quality results in irregular and inconsistent quality of medical records at the grassroots level.Insufficient application of digital technology hinders the informatization process of grassroots medical records.The development of grassroots medical record information should be promoted from five aspects,including raising awareness of the importance of grassroots medical record information management,strengthening talent team training and standardized training,promoting the integration of electronic medical record systems and the construction of quality control systems,improving the popularization and management level of electronic medical records in application,and promoting the realization of electronic medical records within the medical consortium.Sharing and mutual recognition,so as to provide a reference for improving the country's grassroots medical record information management.

关 键 词：基层社区 公共卫生服务 病案 信息化管理 

分 类 号：R197.323[医药卫生—卫生事业管理]