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目的探索具有人性化理念的病案管理及信息利用的管理模式。方法根据临床需要及各类用户需求,开发病案信息,充分发挥病案的作用。结果病案信息除满足医院管理、医、教、研外,逐渐被社会各界重视及广泛利用。结论病案信息是重要的医疗资料,加强病案质量管理有助于防范医疗纠纷及安全利用病案信息,科学、规范地开发病案信息显得非常必要。
Objective To explore the management mode of medical record management and information utilization with humanized concept. Methods According to clinical needs and various types of users’ needs, develop medical record information and give full play to the role of medical records. Results In addition to meeting the hospital case management information, medical, teaching, research, gradually by all sectors of society attention and widely used. Conclusion Medical record information is an important medical information. It is very necessary to strengthen the medical record quality management to prevent medical disputes and to use medical record information safely and scientifically and normatively.