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目的探索与思考高效的病案信息开发工作应具备的要素,为临床科研提供高质量信息。方法通过对病案信息利用的认识和分析,结合文献查阅相关概念。结果总结出高效的病案信息开发工作应具备的要素主要包括:基础数据准确,检索条件清晰,数据联结完整。结论加强病案信息开发,提高病案信息利用率,体现病案管理的真正价值,为临床提供高效服务。
Objective To explore and consider the elements that should be possessed by efficient medical record information development to provide high quality information for clinical research. Methods Through the knowledge and analysis of medical record information, combined with the literature access to related concepts. The results summarize the key elements that should be possessed by efficient medical record information development: accurate basic data, clear retrieval conditions and complete data connection. Conclusions Strengthen the development of medical record information, improve the utilization rate of medical record information, reflect the true value of medical record management and provide efficient service for clinic.