综述病案信息的应用和管理

文章分析了病案信息在医院管理、临床研究与临床流行病学研究、社会医疗保险和商业保险以及病人、公安、司法等部门的应用。在新形势下发挥病案信息应有的价值,首先要加强病案信息质量管理;其次要充分利用现代化的管理工具;树立新观念、改变服务模式,创造性的开展病案管理编研服务,使病案信息能得到最大限度的应用。在应用的同时还需加强病案信息的安全管理,既方便使用,做到资源共享,又能防止非法泄露,避免对集体及个人造成不利影响。最后探讨了电子病案是医院信息系统的核心,是医院信息现代化的必然趋势,是医学领域一场深刻的信息革命,对医疗卫生事业产生深远的影响。

The Application and Management Summary of Medical Record Information

This paper analyzes the application of medical record information in the hospital management,clinical research and clinical epidemiology,social health insurance and commercial insurance as well as patients,public security,judicial departments.The value of medical record information should be played in the new situation.First,strengthen the medical record information quality management.Second,make full use of modern management tools,establish new concepts,change service modes,creatively carry out medical records management coding and research services.We need to strengthen the safety management of the medical record information at the same time.Not only easy-to-use and resource sharing,but also preventing the illegal disclosure,avoid adverse impact on the collective and individual.The electronic medical record is the core of the hospital information system,is the inevitable trend of modern hospital information,and the medical field a profound information revolution.It has a profound impact on medical and health undertakings.