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目的探讨电子病案的广泛应用促进病案管理的职能改变。方法通过电子病案与纸质病案在组织结构、工作流程、工作方式等方面存在的差异进行比较。结果电子病案以其信息采集速度快,信息存储容量大,占用存储空间小,检索使用方便、快捷,并能实现广域网信息数据交流与共享等优势,将成为全面实现以“病人为中心”的人性化管理模式的转变的催化剂。结论必须加快推广、规范电子病案的临床应用,全面提高病案管理人员以及全体医护人员的业务素质与技能,才能实现病案管理职能全方位的转变。
Objective To explore the wide application of electronic medical records to promote the change of medical records management functions. Methods The differences between organizational structure, work flow and working methods of electronic medical record and paper medical record are compared. Results E-medical records, with its advantages of fast information collection, large information storage capacity, small occupied storage space, convenient and fast searching, wide area network information data sharing and sharing, will become the centerpiece of “patient-centered” The catalyst for the change of human management mode. Conclusion It is necessary to speed up the promotion, standardize the clinical application of electronic medical records, and comprehensively improve the professional qualifications and skills of medical record administrators and all medical staff in order to achieve a full range of changes in medical record management functions.