论文部分内容阅读
病案管理是医院现代化管理的重要组成部分,病案的使用已经从医院的医、教、研需要延伸、扩展到社会经济生活的各个领域,其特有的原始创造性、唯一性更加显示出其重要作用。因此,必须强化病案管理工作,狠抓病案质量,认真书写病案,确保病案内容的准确与完整;做好疾病编码、录入、检索工作,充实与完善病案信息库;严格遵守病案管理制度,保管好病案,才能更好地、全方位地服务于社会,促进病案管理工作不断发展与提高。
Medical record management is an important part of modern hospital management. The use of medical records has been extended from the medical, teaching, and research needs of the hospital to various fields of social and economic life. Its unique original creativity and uniqueness have shown its important role. Therefore, we must strengthen the management of medical records, pay close attention to the quality of medical records, write medical records seriously, ensure the accuracy and completeness of the medical records, do a good job in disease coding, entry, and retrieval, and enrich and improve the medical record information base; strictly abide by the medical record management system and keep it well. The medical record can serve the society better and all-round, and promote the continuous development and improvement of medical record management work.