再议病案信息的采集

病案信息是医院档案管理工作中的重要组成部分，病案是医院医疗诊治过程中，所形成的重要文字记载，记录着患者整个诊疗病程，隶属永久保存档案材料。病案信息采集数据必须及时、准确、真实、可靠，采集的各个环节都要引起广大医务人员的足够重视，不能有丝毫马虎。要有严格统一的信息采集质量标准，进行合理的规划管理，建档立制，进一步合理完善，做好信息质量评价、反馈。

Reconsideration of Information Collection of Medical Records

Medical records,main written records of diagnosis and treatment,are an important part of hospital file management,which should be preserved permanently.Information of medical records should be collected opportunely,accurately,truly and reliably.All aspects during collection must be paid enough attention.Moreover,information collection should strictly uniform quality standards.Rational planning and management,archiving systems,further perfection,good evaluation and feedback of information quality are also im...