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病案不仅代表着一所医院的医疗技术水平,也反映着医院的管理经营能力。随着医疗机构体制改革的深入以及社会信息化的飞速发展,病案信息资源开发利用已成为病案管理部门主动为医院医疗、教学、科研、管理以及社会服务的重要手段。尤其是在即将实施的医疗保险制度中,更能体现其价值和作用。传统的病案信息管理以往大多局限于单一病案的收集、整理、登记和保管,而忽视了病案内涵信息的有效利用。在医疗卫生改革新形势下,病案管理人员要充分认识病案信息资源在医院管理和社会服务中的积极作用,才能在医疗市场经济中,变被动服务为主动服务。
The medical record not only represents the medical technology level of a hospital, but also reflects the management and management capabilities of the hospital. With the deepening of the institutional reform of medical institutions and the rapid development of social information, the development and utilization of medical record information resources has become an important means for the medical record management department to actively serve the hospital for medical treatment, teaching, scientific research, management, and social services. Especially in the upcoming medical insurance system, it can better reflect its value and role. In the past, traditional medical record information management was mostly limited to the collection, sorting, registration, and safekeeping of a single medical record, while ignoring the effective use of medical record information. Under the new situation of medical and health reform, the medical record management personnel must fully understand the positive role of medical record information resources in hospital management and social services so that they can change passive services into active services in the medical market economy.