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目的总结目前病案信息利用中存在的问题,探索提高病案信息利用率的方法。方法建立病案检索体系;转变观念,培养病案管理人员信息意识,开发病案二次、三次情报、专题情报;设置病案保密权限,按部门、职称设定各级人员查阅权限。结果病案信息利用率明显提高。结论开发病案检索体系是加强病案信息利用的基本保证,二次、三次病案情报的加工、专题情报分析可提供高层次病案信息利用,在利用中病案信息加密、按部门、职称设置使用权限,防止因泄密引起纠纷。
Objective To summarize the existing problems in the use of medical record information and explore ways to improve the utilization of medical record information. Methods Establish a medical record retrieval system; change concepts, develop information awareness among medical record managers, develop secondary and tertiary intelligence, and special case information for medical records; set confidentiality rights for medical records, and set up access rights for personnel at all levels according to department and professional titles. Results The utilization rate of medical record information has been significantly improved. Conclusion The development of the medical records retrieval system is the basic guarantee for strengthening the use of medical record information. The processing of secondary and tertiary medical record information and thematic intelligence analysis can provide high-level medical record information utilization. In the use of medical record information encryption, the usage authority is set by department and job title to prevent Disputes caused by leaks.