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医院病历档案是医院临床、教学、科研工作的宝贵材料,是记录医疗信息的原始资料,同时也是法律性文件,病案信息管理是保证医疗质量的关键。以此,建立和完善病历档案管理信息,使病历档案的管理法制化、规范化,把病历档案原始记录转化为活的可用信息,为医院医疗、教学、科研流程开发利用。本文从北京市昌平区妇幼保健院病历档案信息的开发和利用的意义出发,浅议病历档案信息的管理与应用,提出相应的建议。
Hospital medical record is a valuable material in clinical, teaching and scientific research. It is the original material to record medical information and is also a legal document. The medical record information management is the key to ensure medical quality. In this way, the establishment and improvement of medical record file management information, the medical records file management legalized and standardized, the original records of medical records into living information available for the hospital medical, teaching, scientific research and development process. This article from the Changping District of Beijing Maternal and Child Health Hospital, the significance of the development and utilization of medical records file information on the management and application of medical records information, put forward the corresponding recommendations.