做特殊病案总结 提高病案利用价值

目的对病案中的新病种、疑难复杂疾病、急危重症,新的医疗、技术、设备、护理的实践,包括疗效的观察、经验教训等进行总结,做成“特殊病案总结”,以区别于普通病案,让更多的人共享,从而提高病案的利用价值。方法由主管医师从出院病案中提取“特殊”,副主任医师以上签阅生效,附在出院病案后面并输入计算机处理(为维护病人隐私可不输入姓名)。结果从病案的各组成部分入手,分析了特殊病案常常会在哪些方面“特殊”。结论“特殊病案总结”能对出院病案的利用起到提纲挈领的作用,特别是经过计算机处理以后,能使长年沉睡的大量出院病案更好地为医学服务。

The Summary of the Special Medical Records to Enhance the Value of Medical Records

Objectives To sum up the new, difficult and complex records, critical diseases, the practical experiences of new medical technique, e-quipment and nurses' practice. As special medical record summarizations which differentiated from normal medical record, They can be shared by more people. Special medical record summarization can enhanced the value of medical record. Methods The special medical records selected by the chief doctors and confirmed by assistant director doctors will be attached to the discharged medical records, and setting - up the e - record reports. Results The writer analyzed the compositions of the special medical records, and wrote a special medical record as example. Conclusion Special medical record summarization can concentrate on the main points of discharged medical records, especially setting- up the e- record report can improve the management of dormant of the medical records of the discharged patients.