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远程医疗会诊病案资料的收集与管理
引用本文:连平,徐祖铭,崇抗美,翟新海,宁义. 远程医疗会诊病案资料的收集与管理[J]. 解放军医院管理杂志, 2001, 8(2): 88-89
作者姓名:连平  徐祖铭  崇抗美  翟新海  宁义
作者单位:1. 第85医院信息科,全军远程医学研究开发基地,
2. 总后勤部卫生部信息中心,
摘    要:为探索远程医疗会诊接受对会诊业务活动中生成的各类病案资料的收集与管理方法,本对569例次远程医疗会诊生成的“会诊申请病历”、“影像图片”、“会诊专家书面意见”及“会诊实况录相”4种不同病案资料进行了收集,并采用自建编码方式完成病案资料的建档管理。作认为,全面、认真收集远程病案资料,科学、有序地加以管理,是提高现代远程医疗会诊质量,并确保此项医疗活动得以延续的重要工作内容。在日常工作中,也能极大地方便对病案资料的调阅、数据统计、远程医疗复诊、随访和科研总结工作等。

关 键 词:远程医疗 病案 管理
文章编号:1008-9985(2001)02-0088-0089-02
修稿时间:2000-12-05

Collection and Managementof Patient Record and Material for Telemedicine Consultation
LIAN Ping. Collection and Managementof Patient Record and Material for Telemedicine Consultation[J]. Hospital Administration Journal of Chinese People's Liberation Army, 2001, 8(2): 88-89
Authors:LIAN Ping
Abstract:To develop the method for collection and management of all sorts of patient records generated in telemedicine activities at referring site, we have collected patient records, which are sorted in four different types:patient record for applying tele-consultation, medical image, medical specialists' diagnosis and tape-record of teleconsultation, in 569 teleconsultations. Also, we have completed the archiving and management of patient records by self-made encoding method. We should collect patient records completely and carefully and manage them with scientific method. It's important for improving quality of tele-consultation, ensuring the expanding of this medical activity,making it convenient in daily working for patient records' reviewing, data statistic, further tele-consultation, follow-up and research reporting etc.
Keywords:
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