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病案信息管理是当前医院管理的重要组成部分。病案作为医疗信息的重要资源,为临床、教学、科研和医院精细化管理、科学决策提供了宝贵的第一手资料,成为新医改重要的抓手。整理某院自1949年建国以来存档的病案,对历史病案进行数字化扫描,同时采用ICD-10和ICD-9-CM-3对历史病案进行疾病和手术编码的补录。历史病案是医学资料的传承载体,通过历史病案了解医学的变化形势,为目前的编码工作提供借鉴和支撑。数据的延续反映出医院病案管理发展的历史轨迹,具有重要的历史、艺术和科学价值和历史传承的意义,弥足珍贵。
Medical record information management is an important part of hospital management. As an important resource for medical information, medical records provide valuable first-hand information for clinical, teaching, research and hospital fine management and scientific decision-making and become an important starting point for new medical reform. Organize the medical records archived in a hospital since its founding in 1949, digitally scan historical medical records, and supplement the historical medical records for disease and surgery using ICD-10 and ICD-9-CM-3. Historical medical records are the carrier of medical information, understand the changing situation of medicine through historical medical records, provide reference and support for the current coding work. The continuation of the data reflects the historical trajectory of the development of medical record management in hospitals, which is of great value in historical, artistic and scientific value and historical heritage.