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病案是医院管理的重要医疗档案,是临床医疗质量的反映,是处理医疗差错的法律依据,是一个宝贵的信息库。加强病案管理,提高病案质量是医院科学管理的重要内容之一。我所1989年8月开始接纳病人起成立的心血管专科(包括内、外、儿科)病案室。现介绍如下。 (一)制定标准化管理制度: 1.病案入库后按标准化程式处理: 对每份病案的处理程序应包括几个项目,使其成为一份有价值的完整病案,病案送回病案室时就开始按照这套程序进行处理,包括检查、整理、分科登记、疾病名称分类编码,以及编制各类型索引卡和质
The medical record is an important medical file for hospital management, a reflection of clinical medical quality, a legal basis for handling medical errors, and a valuable information database. Strengthening medical record management and improving the quality of medical records are one of the important contents of hospital scientific management. In August 1989, our institute began accepting patients from the establishment of the Cardiovascular Specialties (including internal, external, and pediatric) case. The introduction is as follows. (1) Formulating a standardized management system: 1. A standardized procedure is adopted after the case is put into the warehouse: The procedures for the handling of each case should include several items, making it a worthwhile and complete case, when the case is returned to the case Start processing according to this set of procedures, including inspection, sorting, sub-divisional registration, disease name classification coding, and the preparation of various types of index cards and quality.