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病案是医院的主要医疗信息载体,贯穿于医院管理的全过程,是医院管理的基础和核心。随着信息科学的飞速发展,病案管理已走向卫生信息管理,由单纯的回收、整理、装订、编号、归档和供应发展成为科学化、规范化和信息化的医疗管理系统,并产出大量有价值的信息。这些信息是否完整及规范直接关系到医院的管理水平,关系到医院各项工作制度的落实。
Medical record is the hospital’s main medical information carrier, which runs through the whole process of hospital management and is the foundation and core of hospital management. With the rapid development of information science, medical record management has moved toward health information management and has been developed into a scientific, standardized and informatized medical management system from simple collection, sorting, binding, numbering, filing and supply and has produced a great deal of value Information. The completeness of these information and norms are directly related to the management level of the hospital and are related to the implementation of the hospital’s various work systems.