国内医院引入“数字化病案”必要性探讨

目的随着我国医疗制度、医疗保险制度的不断完善，病案使用率超前增涨；各大医院病案管理越来越严格，而病案存储空间越来越紧张，为进一步探索病案管理的科学方法，探讨医院病案管理的科学发展趋势。方法通过分析医院病案管理、存储、使用现状。结果总结病案管理的需求特点与原则及发展的三个阶段性，寻找现行病案管理工作的缺点和不足，比较“数字化”病案优势。结论“数字化”病案阶段是国内各大医院病案管理的必经之路，它是一个承上启下的不容跨越的重要阶段，引入“数字化病案”非常必要。

The Necessity on Introducing the"Digital Medical Record"in the Hospitals

Objective With the medical and insurance systems improved continuously in China, and the greater utilization rate of medical records, almost every major hospital with strict management of medical records is bothered with the dilemma between the limited storage room and unlimited increasing amount of medical records. So we want to explore the trend and then develop the scientific management methods. Method We analyzed the management, storage, and utilization of medical records. Result Based on the conclusion involving the demanded characteristics, principles and three steps of the development of medical records, we found the advantages of "digital medical records" in management and compared them with the shortcomings and deficiencies. Conclusions It is necessary to introduce the "digital medical records", because it is the only way and an important means to link the present with future.