未归集到电子病历系统中的纸质病案的管理

在电子病历系统的应用过程中,仍然有未归集到电子病历系统中的纸质病案的存在,常见的不能直接归入电子病历系统的纸质病案主要是知情同意签字单、特殊的检查报告单、高值耗材条码粘贴记录单等,这些不论是患者的后续医疗,还是法律作用,都是非常重要的病案资料。对于这部分未能直接归入电子病历系统的病案资料,医院制定相应的管理制度,根据实际情况列出纸质病案清单,便于病案归档时的核对,病房医护人员注意纸质病历的保存和管理,病案科对于收回的纸质病案进行核对、整理、数字化、装订、入库保存,复印借阅按照规定执行。将未能归集到电子病历系统中的纸质病案进行数字化,常采用扫描的方法,形成图像文件,再转换成标准的FDP格式,存储到病案服务器中,与电子病历系统对接,形成一份完整的电子病案资料。以达到病案归档的完整性,便于信息利用。

Management of Paper Medical Records in Electronic Medical Record System

At present,in the application process of electronic medical record system,there are still paper medical records.The paper medical records which can not be classified into the electronic medical record system should have corresponding management measures.According to the function of the electronic medical record system and whether the electronic signature authentication has been carried out,how many paper medical records can not be included in the electronic medical record system.The common paper medical records that can not be directly included in the electronic medical record system are the signature form of informed consent,the special inspection report form,and the barcode pasting record sheet of high-value consumables.Whether it is the follow-up medical treatment of patients or the role of law,they are very important medical records.For this part of the medical records that can not be directly included in the electronic medical record system,the hospital should formulate the corresponding management system.According to the actual situation,the paper medical record list should be listed to facilitate the check of medical record filing.For paper medical records,scanning method is often used to form image files,and then converted into standard FDP format,stored in the medical record server,the electronic medical record system docking,forming a complete electronic medical record data.To achieve the integrity of medical records and easy to use.