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我院是一所“三甲”综合医院和医学院的教学医院,我院心血管内科和风湿内科被列为“211工程”的重点学科,故科研项目多,教学任务重。随着医院的发展,高新技术的运用,新科研成果的出现,总结研究使用病案越来越多;范围越来越广,要求越来越高。在新形势下,管好病案、把好病案质量关,积极开发和利用病案资源,主动为临床提供高质量的服务,是每一个病案管理人员应该面对和重视的问题。在实践中我们不断总结经验,收到一定的成效。
Our hospital is a teaching hospital of the “three-A” general hospital and medical school. Our Department of Cardiology and Rheumatology is listed as a key discipline of the “211 Project”. Therefore, there are many scientific research projects and teaching tasks are heavy. With the development of hospitals, the use of new and high technologies, and the emergence of new scientific research results, more and more medical records have been summed up; the scope has become wider and wider, and demands have been increasing. Under the new circumstances, it is an issue that every medical record management personnel should face and attach importance to managing medical records, putting quality records in order, actively developing and using medical resources, and actively providing high-quality clinical services. In practice, we constantly sum up experience and receive certain results.