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门诊病案的建立当前没有引起足够重视,在建立的过程中也存在一些问题,主要是病人对传统门诊病案保存意识需要引导、医院门诊病案管理意识需要加强、门诊病案的计算机技术需要完善三个方面。门诊病案的建立,对医院和患者双方都具有重要的法律意义,对于建立新型的医患和谐关系具有重要的作用。同时对于医院考核门诊医生工作质量建立了科学指标,对医疗教学科研也具有重要的医学资料价值。
The establishment of outpatient medical records has not attracted enough attention at present. There are also some problems in the process of establishment. The main problems are that patients need to guide the traditional awareness of medical record preservation, the need for in-patient medical record management awareness needs to be strengthened, and the outpatient medical record computer technology needs to be improved. . The establishment of an outpatient medical record has important legal significance for both hospitals and patients, and plays an important role in establishing a new type of harmonious relationship between doctors and patients. At the same time, it has established scientific indicators for the work quality of outpatient clinic doctors, and has important medical data value for medical teaching and scientific research.