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目的通过对我院病案信息资源利用情况进行分析,促进医师规范书写病历,重视病案质量。方法采用Excel软件计算百分率及构成。结果病案资料对内主要用于医务人员课题研究和质控专家进行终末病历质控时调用,对外则以病人及其家属和保险公司调查人员调用居多。结论保管好病案的目的是为了能使病案资料得到最好的利用。病案人员要提高病案资料的利用频率,应注重信息服务的质量和效率,以体现其价值所在。
Objective By analyzing the utilization of medical record information resources in our hospital, we can promote the physicians to standardize the writing of medical records and attach importance to the quality of medical records. Methods Using Excel software to calculate the percentage and composition. Results The medical records were mainly used for medical personnel research and quality control experts to call for the end of the year when the quality of medical records control, while the external is the patient and their families and insurance company investigators call the majority. Conclusion The purpose of keeping the medical record is to make the best use of the medical record data. Medical staff to improve the frequency of use of medical records should focus on the quality and efficiency of information services to reflect its value.