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为了保障临床路径工作的顺利实施,作为病案管理人员要更新管理理念,变被动为主动,认真学习卫生部制定的临床路径标准中各病种准入细则,掌握各病种的临床分型、分期和治疗方式,积极参与临床路径工作。在病种筛选中编码员应深入病房,加强与临床医师间的沟通,不断提高专业技能水平和临床医学知识;以保证临床路径资料的准确性。只有提高病案信息质量,才能体现病案的利用价值。为临床路径的逐步推广和实施打下坚实的基础。
In order to ensure the smooth implementation of the clinical pathway, as the medical record management personnel to update the management concept, change from passive to active, earnestly study the clinical pathway standards formulated by the Ministry of Health access to the details of the various diseases, to grasp the clinical types of diseases, staging And treatment, and actively participate in clinical pathways. In the screening of disease types, the coder should go deep into the ward, strengthen communication with clinicians, continuously improve the professional skill level and clinical medicine knowledge, and ensure the accuracy of clinical path data. Only by improving the quality of medical record information can we reflect the value of the medical record. Lay a solid foundation for the gradual promotion and implementation of clinical pathways.