医院病案管理信息化发展的机遇与挑战  

Opportunities and Challenges of Informationization Development in Hospital Medical Record Management

作　　者：曾红梅 廖永明 罗盛芬 ZENG Hongmei;LIAO Yongming;LUO Shengfen(Medical Record Room,Zheng'an County People's Hospital,Zunyi 563400,Guizhou,China)

机构地区：[1]正安县人民医院病案室,贵州遵义563400

出　　处：《中国卫生产业》2024年第24期144-148,共5页China Health Industry

摘　　要：随着医疗体系改革的持续推进,医院逐步推进以“互联网+医疗”为特色的医疗服务创新。本文探讨了医院病案管理信息化发展的机遇、挑战与优化实施策略。病案数据网格化促进了信息共享,医生能够快速获取患者信息,病例历史资料保存完整。但是医院病案管理信息化发展也面临一定的挑战,对病案软件和计算机知识需求较高,病案数据利用率有待提升。为了优化医院病案管理信息化发展,本文提出实现全病历无纸化,优化病案库房管理,利用自动纠错功能促进病历质量管理,优化管理流程,发挥AI技术优势,促进医院病案管理精准编码。在实践中提升医院病案管理的信息化水平,为患者提供更好的医疗服务。医院有效地利用病案资源,促进病案管理信息化转型。With the continuous advancement of the reform of the medical system,the hospital has gradually promoted the medical service innovation characterized by"Internet plus medicine".This article explores the opportunities,challenges,and optimization implementation strategies for the informatization development of hospital medical record management.The gridding of medical record data promotes information sharing,allowing doctors to quickly access patient information and preserve complete case history data.However,the development of informationization in hospital medical record management also faces certain challenges,with a high demand for medical record software and computer knowledge,and the utilization rate of medical record data needs to be improved.In order to optimize the development of hospital medical record management informatization,this article proposes to achieve paperless management of all medical records,optimize the management of medical record warehouses,use automatic error correction functions to promote medical record quality management,optimize management processes,leverage the advantages of AI technology,and promote accurate coding of hospital medical record management.To enhance the informatization level of hospital medical record management in practice and provide better medical services for patients.Hospitals effectively utilize medical record resources and strengthen the informatization transformation of medical record management.

关 键 词：医院病案管理 信息化 病案利用 病历质量管理 

分 类 号：R19[医药卫生—卫生事业管理]