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1 前言病案是住院患者的医疗案卷,也是医院医教研丰富信息资料的宝库。病案管理的手段及现代化程度反映了一个医院的管理、医疗、教学、科研的质量与水平。病案信息数据量大,涉及面广,是现代医院的一项重要信息资源。而要使它得到充分的利用,靠传统的落后的手工管理方法,已不能适应现代医院管理要求,必须要用现代化的手段管理。目前,部分医院病案首页实行了微机管理,这对于提高工作效率和管理水平,实现病案管理的科学化、规范化,加速病案管理的现代
1 Introduction The medical record is the medical record of an inpatient. It is also a treasure house of hospital medical education and research. The means of medical record management and the degree of modernization reflect the quality and level of a hospital’s management, medical care, teaching, and scientific research. The large amount of medical record information data, covering a wide range, is an important information resource for modern hospitals. In order to make full use of it, relying on the traditional backward manual management methods, it can no longer meet the requirements of modern hospital management and must be managed with modern means. At present, some hospitals have implemented computer management on the front page of medical records. This is to increase work efficiency and management level, to achieve scientific and standardized medical record management, and to accelerate modern medical record management.