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随着医学科学的发展,病案管理已成为医院管理的一个重要方面。多年来,我们在加强病案管理及提高病历质量方面作了一些尝试和探索,介绍如下。 1 病案是医疗工作的全面记录,反映着疾病的全过程,是医护人员进行正确诊断、抉择治疗和护理的科学依据;体现着医院的医疗质量、管理水平和医护人员的业务素质;同时还是临床医疗教学科研、信息管理的重要组成部分。因此,必须以认真负责、实事求是的科学态度做好病案管理工作。
With the development of medical science, medical record management has become an important aspect of hospital management. Over the years, we have made some attempts and explorations in strengthening the management of medical records and improving the quality of medical records, as described below. 1 The medical record is a comprehensive record of medical work, which reflects the whole process of the disease. It is the scientific basis for the correct diagnosis, choice of treatment and care by medical personnel; it embodies the hospital’s medical quality, management level and the professional quality of the medical staff; it is also clinical Medical teaching and research, information management, an important part. Therefore, we must do a good job in the management of medical records with a scientific attitude of conscientiousness and responsibility and seeking truth from facts.