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住院病案实行电子无纸化病案和电子签名管理是今后病案管理的发展方向,新的管理模式需要制定相应的病案管理制度,我院在实行无纸化病案管理的过程中,从人员的准入、病历书写痕迹修改、书写时限的规定、电子病案的回归、保管、打印、病案归档后的查阅和归还功能等制定了相应的管理制度,为丰富和完善我国的病案管理作参考。
Inpatient medical records of the implementation of electronic paperless medical records and electronic signature management is the future direction of the development of medical records management, the new management model requires the development of appropriate medical records management system, our hospital in the implementation of paperless medical records management, access from staff , The revision of medical history writing, the stipulation of writing time limit, the return of electronic medical records, custody, printing, filing and restitution functions after medical records filing, and so on, formulated corresponding management systems for reference to enrich and perfect the medical records management in our country.