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为了提高病案的利用率和病案科的服务质量,首先分析病案管理现状,存在的主要问题有病案资料不完整和病案管理人员不足等,直接影响了病案的利用率。从而提出病案管理人员主动服务的理念。主动与临床科室沟通,了解临床科室的需求,满足临床科研、评审等需求;了解与编码有关的医学知识,提高编码的准确性。主动了解医院管理的需求,提高准确的统计信息。主动了解患者的需求,提供良好的复印服务。同时制定相关的制度,以保证病案管理质量,确保提供信息的准确性。增强主动服务意识,可提高病案信息的利用率,促进病案管理水平的提升。
In order to improve the utilization rate of medical records and the service quality of medical records, the first analysis of medical records management status quo, the existence of the main problems are incomplete medical records and medical record management staff, which directly affect the utilization rate of medical records. Thus put forward the concept of medical service management initiative. Take the initiative to communicate with clinical departments, understand the needs of clinical departments, and meet the needs of clinical research and assessment; understand the medical knowledge related to coding and improve the accuracy of coding. Take the initiative to understand the needs of hospital management and improve accurate statistical information. Take the initiative to understand the needs of patients, provide good copy services. At the same time to develop the relevant system to ensure the quality of medical records to ensure that the accuracy of information provided. Enhance the awareness of active service, can improve the utilization rate of medical record information, and promote the improvement of the medical record management level.