摘要
病案首页是医务人员使用文字、符号、代码、数字等方式,将患者住院期间相关信息精练汇总在特定的表格中,形成病例数据摘要。随着医院信息化建设的深入发展,病案首页在管理过程中逐渐融入计算机管理内容,通过计算机管理在一定程度上实现了病案首页管理的信息化发展,在一定程度上降低了人力操作的重复性,确保病案数据的可查询性。但是针对病案首页,计算机管理过程中依然存在诸多问题,需要积极采取有效的应对措施,做好相应的管理工作,以此保证病案首页管理的科学性。
The first page of medical record is used by medical staff to elaborate and summarize relevant information of patients during hospitalization in a specific table to form case data summary by using words,symbols,codes and numbers.With the in-depth development of hospital information construction,the first page of medical records is gradually integrated into the content of computer management in the management process,through computer management to a certain extent to achieve the information development of the first page of medical records management,to a certain extent to reduce the repeatability of human operations,to ensure the queryability of medical records data.However,there are still many problems in the process of computer management of the first page of medical records,so it is necessary to take active and effective measures to ensure the scientific management of the first page of medical records.
作者
徐博学
谈优
徐波
XU Boxue;TAN You;XU Bo(Case Room,Yixing Hospital of Traditional Chinese Medicine,Yixing,Jiangsu Province,214200 China;Medical Department,Yixing Hospital of Traditional Chinese Medicine,Yixing,Jiangsu Province,214200 China)
出处
《中国卫生产业》
2023年第19期244-246,251,共4页
China Health Industry
关键词
计算机管理
病案首页
病案管理
Computer management
First page of medical record
Medical record management
