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随着社会主义市场经济体制的确立,全国范围内的医疗保险制度逐步施行,病案管理对医院的经济监督职能越来越强;社会保险事业的迅速发展,与疾病和保健有关的多种险种的开发,使社会保险部门与医院的病案管理部门的关系越来越密切;社会发展趋向的信息化与法制化,人们的自我保护意识增强,通过合理使用病案信息来维护自身住院就医的合法权益的案例也在逐年增多,病案信息充分体现了其法律证据性;再加之以其他各级执法机关、卫生防疫、计划生育部门及科研单位等各种社会机构对病案信息的广泛需求,致使病案管理部门的社会工作越来越多。病案信息管理服务一改以前的仅向医院内部开放,为医、教、研提供服务的传统服务模式,逐渐发展成为一个需大量接洽社会工作,参与医院整体的经济管理、诊疗评判与综合决
With the establishment of the socialist market economic system, a nationwide medical insurance system has been gradually implemented, and the case management has become more and more powerful for the hospital’s economic supervision. The rapid development of social insurance and the diversification of disease and health-related insurance Development and make the social insurance departments and the hospital’s case management department closer and closer; the trend of social development and legalization of information, people’s awareness of self-protection, through the rational use of medical records to safeguard their own legal rights of hospitalized medical treatment The number of cases is also increasing year by year. The medical record information fully embodies its legal evidence. In addition, the extensive demand for medical record information from various social institutions such as law enforcement agencies at all levels, health and epidemic prevention departments, family planning departments and scientific research institutes, More and more social work. The medical record information management service has been transformed into a traditional service mode that was only open to the internal hospitals and provided services for medicine, teaching and research. It gradually developed into a social service that requires a lot of engagement with the society, participation in the overall economic management, diagnosis and treatment of hospitals,