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病案由不同项目组成,承载的功能不同,产生的信息不同,数据的使用客户不同,但病案中生成的信息数据质量的要求是相同的。随着医疗体制改革的深化和需要,重视病案信息数据质量被越来越多的政府部门达成共识。搭建中国临床医疗大数据库,保证每份病案中产生的信息质量是最基本的条件。数据的完整、精细必须能够为党和国家高层领导集体提供推进医改的依据和顶层设计的正确度。关注病案中产生不同信息质量的管理技术,改进其中的技术缺陷,在电子病案技术的辅助下,信息数据真实、完整、可靠,供任何客户共享,产生管理和经济效益,达到病案信息管理学科的最高目的,即信息及数据的深度利用。
The medical record consists of different items and carries different functions, resulting in different information and different data users. However, the quality of information and data generated in medical records is the same. With the deepening and the need of medical system reform, more and more government departments have reached a consensus on how to attach importance to the quality of medical record information data. It is the most basic condition to set up a large Chinese clinical database to ensure the quality of information generated in each case. The completeness and sophistication of the data must provide the party and the country’s top leadership with the basis for promoting health reform and the accuracy of the top-level design. Pay attention to the management techniques that produce different information quality in the medical records and improve the technical defects therein. With the help of the electronic medical records technology, the information data is true, complete and reliable, and can be shared by any customer, resulting in the management and economic benefits, reaching the discipline information management disciplines The ultimate goal is the deep use of information and data.