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病案管理是医院现代化管理的重要组成部分,病案信息的使用已从单纯的查询、医学教研延伸、扩展到社会经济生活的各个领域,其特有的原始创造性、唯一性更加显示出其重要作用。因此,强化医院病案管理工作,狠抓病案质量,认真书写病案,确保病案内容的准确和完整,做好疾病编码、录入、检索工作,充实和完善病案信息库,严格遵守病案管理制度,保管好病案,保证病案信息的安全有效使用,全方位地服务于社会,适应时代的需求,是新形势下对病案信息管理者的基本要求。
Medical record management is an important part of hospital modernization management. The use of medical record information has expanded from simple inquiry and medical teaching and research to various fields of social and economic life. Its unique original creativity and uniqueness have shown its important role. Therefore, we must strengthen the management of medical records in hospitals, pay close attention to the quality of medical records, carefully write medical records, ensure the accuracy and completeness of medical records, and do a good job in disease coding, entry, and retrieval, enrich and improve the medical record database, and strictly abide by the medical record management system. Medical records, ensuring the safe and effective use of medical record information, serving the society in all directions, and adapting to the needs of the times are the basic requirements for medical record information managers in the new situation.