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病案室工作档案的建立与病案管理质量息息相关,病案室管理的病案数量巨大,流动频繁,贮存年代长久,要求检索的条件多样,工作接触面广。随着时间的延续、人员更迭,科学的进展,工作常规、方法、流程的改变,不注重工作档案的建立,常因无文字记述给病案资料的检索查找造成困难,甚至资料的掩埋。方法建立工作档案将各时期的制度、工作方法、流程、工作变迁记录在案。结果较好的传承病案资料的管理,保护医学科研成果最基础的信息资料,也是一部医院医教研和医院管理完整的档案资料,保障病案室工作的顺利开展。
The establishment of work files in case files is closely related to the quality of medical record management. The number of medical records managed by case files is huge, the flow is frequent, and the time of storage is long. The conditions for searching are diverse, and there is a wide range of work contacts. With the continuation of time, changes in personnel, scientific progress, changes in work routines, methods, and procedures, and the lack of attention to the establishment of work files, it is often difficult to find and retrieve medical records because of the absence of written records. Methods The establishment of work files records the systems, work methods, processes, and work changes of each period. As a result, the management of medical record data is well preserved, and the most basic information data for the protection of medical scientific research achievements is also a complete archive of hospital medical teaching and research and hospital management to ensure the smooth development of the work of the medical record room.