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一份设计合理的病案表格是保证病案质量的前提和基础。随着临床医学的发展,临床工作方法流程发生了一些变化,病案管理者必须依据临床工作的新特点不断改进和完善病案表格的格式和内容,同时病案表格在设计上还需要满足当前“举证责任倒置”的法律要求。医院应在制度上加强病案表格的管理,使管理工作规范化,法制化。医院数字化信息系统的广泛应用对病案表格管理提出了更高的要求,病案管理者必须依据新形式、新特点探索新的病案表格管理模式。
A well-designed medical record form is the premise and foundation for the quality of the medical record. With the development of clinical medicine, some changes have taken place in the flow of clinical work methods. The medical record manager must continuously improve and perfect the format and content of the medical record form based on the new features of clinical work. At the same time, the medical record form is designed to meet the current “proof Liability inversion ”legal requirements. The hospital should strengthen the management of medical record forms on a systematic basis so as to standardize management and legalization. The extensive application of hospital digital information system puts forward higher requirements on the medical record form management. The medical record manager must explore the new medical record form management mode based on the new forms and new characteristics.