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目的探求实施病案数字化面临问题的解决方法。方法与传统病案管理比较并基于病案数字化的实践确定流程、方法等。结果实施病案数字化要解决存储方式、加工流程、质量控制和经费等问题,还要建立病案数字化管理系统,与HIS连接,才能实现病案数据的在线传送和共享;杜绝病案丢失、损坏;减少存储空间;提高病案对外利用的效率;提升病案管理的水平。结论病案数字化是与无纸化电子病案对接的必由之路,可以提高信息服务的工作效率,改变病案管理模式。
Objective To explore the solution to the problem of digitization of medical records. Methods Compared with traditional medical records management and based on the practice of digital medical records to determine the process, methods and so on. Results The implementation of digital medical records to solve the storage method, processing flow, quality control and funding issues, but also to establish a medical record management system digital, connected with the HIS in order to achieve the online transmission and sharing of medical records; to prevent the loss of medical records, damage; reduce storage space ; Improve the efficiency of medical records utilization; improve the level of medical records management. Conclusion The digitalization of medical records is the only way to connect with the paperless electronic medical record, which can improve the efficiency of information service and change the medical record management mode.