我院纸质病案光盘扫描技术应用的尝试

目的尝试应用光盘扫描技术对我院老旧纸质病案进行现代化管理。方法将所有已归档的死亡病案进行扫描,共有病案约26425份。扫描病案的内容为：首页、出院记录、住院病历、首次病程记录、病程记录、知情同意书、医嘱单、辅助检查报告单、医学影像检查资料、病理报告单、体温单。结果已将所有归档的死亡病案扫描,并刻录制作成光盘。结论⑴改变了病案的阅览方式,方便了病案的复印工作;⑵增加了病案的安全性,减少了病案的磨损和丢失;⑶采用密集架管理,节省了存储空间;⑷光盘保留了原件的历史风貌,能够长期安全保存;⑸与医院HIS系统接连,可以在医院范围内共享医疗数据。

Disc scan paper medical records in our hospital applications try

Objective Trying to apply optical scanning technology to modernize the older paper medical records in our hospital management.Methods All archived death medical records scanning,there are medical records about 26425.Scan the contents of medical records： Home,hospital records,medical records,course records,course records for the first time,informed consent,order form,supplementary information inspection reports,medical imaging,pathology reports,temperature.Results All archived death medical records have been scanned,and burn a CD.Conclusion ⑴ Changed the way medical records access,facilitates the reproduction of medical records;⑵Increase the security of medical records,reducing wear and loss of medical records;⑶An intensive management,saving storage space;⑷Disc of original historical style,the long-term safe storage;⑸Back-to-back with the hospital HIS systems,medical data can be shared within the hospital.