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目的随着我国医疗制度、医疗保险制度的不断完善,病案使用率超前增涨;各大医院病案管理越来越严格,而病案存储空间越来越紧张,为进一步探索病案管理的科学方法,探讨医院病案管理的科学发展趋势。方法通过分析医院病案管理、存储、使用现状。结果总结病案管理的需求特点与原则及发展的三个阶段性,寻找现行病案管理工作的缺点和不足,比较“数字化”病案优势。结论“数字化”病案阶段是国内各大医院病案管理的必经之路,它是一个承上启下的不容跨越的重要阶段,引入“数字化病案”非常必要。
Objective With the continuous improvement of the medical system and medical insurance system in our country, the utilization rate of medical records has surged ahead of schedule. The medical records management in major hospitals has become more and more strict, and the medical record storage space becomes more and more tense. In order to further explore the scientific methods of medical record management Scientific Development Trend of Hospital Medical Records Management. Methods By analyzing the hospital case management, storage, use status. The results summarize the characteristics and principles of the demand for medical records management and the three stages of development, in order to find the shortcomings and deficiencies of the current medical records management and to compare the advantages of “digital” medical records. Conclusion “Digital ” medical record stage is the only way for medical records management in major hospitals in China. It is an important stage that can not be crossed. It is very necessary to introduce “digital medical record”.