住院病案首页标准化研究进展  

Research Progress on Standardization of the Front Page of Inpatient Medical Records

作　　者：日火英支 刘丽华[2] 李林[2] 庄倩 邵梦琪 Rihuo Yingzhi;Liu Lihua;Li Lin;Zhuang Qian;Shao Mengqi(Graduate School of PLA General Hospital,Beijing 100853,China;不详)

机构地区：[1]解放军总医院研究生院,北京市100853 [2]解放军总医院医学创新研究部医院管理研究所,北京市100853 [3]解放军总医院第二医学中心心血管内科,北京市100853 [4]解放军总医院国家老年疾病医学研究中心,北京市100853

出　　处：《中国病案》2025年第3期7-11,共5页Chinese Medical Record

基　　金：医疗大数据集成整合与联合应用重点项目(145BRH010004000X)。

摘　　要：住院病案首页是患者住院期间信息的精炼汇总,对医疗质量控制、医院管理、科研工作及医保支付等方面起着至关重要的作用。通过系统回顾我国住院病案首页标准化的发展历程,分析军队医院住院病案首页的特色信息部分及其修订历程,同时对国外卫生信息标准化的现状进行概述,包括国际标准化组织(ISO)在卫生信息技术领域的标准化工作,以及医学术语标准的构建等。在卫生信息化飞速发展的今天,充分利用标准化信息化手段开展医疗质量管理与控制、加快医院建设、不断提升医疗质量势在必行。应积极进行住院病案首页标准化的深入探索,加强医疗管理控制,完善病案管理,提高医疗机构管理水平和数据利用率。The front page of the inpatient medical record is a concise summary of the patient's information during hospitalization,and plays a vital role in medical quality control,hospital management,scientific research,and medical insurance payment.By systematically reviewing the development of standardization of the front page of inpatient medical records in our country,this paper analyzes the characteristic information part of the front page of inpatient medical records in military hospitals and its revision process.At the same time,this study outlines the current status of health information standardization abroad,including the standardization work of the International Organization for Standardization(ISO)in the field of health information technology and the construction of medical terminology standards.With the rapid development of health information technology today,it is imperative to make full use of standardized information technology to carry out medical quality management and control,accelerate hospital construction,and continuously improve medical quality.Hospitals should actively conduct in-depth exploration of the standardization of the front page of inpatient medical records,strengthen medical management control,improve medical record management,and improve the management level of medical institutions and data utilization.

关 键 词：住院病案首页 标准化 医院 

分 类 号：R197.323[医药卫生—卫生事业管理]