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2011版三级综合医院评审标准中涉及与病案信息利用有关的描述,七章中有378条636款、核心指标48项,与病案信息相关,涉及全部章节有103条,占27.25%;涉及核心条款22项,占45.83%,第七章日常统计学评价几乎占有全部的内容。不少于150余个环节在实施评审中需要利用病案辅助完成,在评审中显示出病案发挥的作用。医院评审标准中还提示,在医院发展中重视病历书写质量的同时,应关注病案信息管理的学术、学科建设和持续改进,促进病案信息的充分利用。
There are 378 items in 6 chapters of the 7 chapters, 48 items of core indicators, which are related to the medical record information, involving 103 chapters in all chapters, accounting for 27.25% of the total. The review covers core Article 22, accounting for 45.83%, Chapter VII of the daily statistical evaluation of almost all the content. Not less than 150 links in the implementation of the review need to use the record to complete the case, in the review showed the role played by the record. The evaluation criteria of hospitals also suggest that while paying attention to the quality of medical record writing in the development of hospitals, attention should be paid to the academic, disciplinary construction and continuous improvement of medical record information management to promote the full utilization of medical record information.