论文部分内容阅读
病案是极其宝贵的医疗信息资源,面对信息技术的进步,病案管理模式也随之相应变化。病案工作人员应转变思路、更新观念、重视信息反馈,增强信息服务水平,变被动为主动,逐步改变传统的管理模式,将病案信息由封闭式资源转向开放式资源,建立病案信息管理的新模式。同时,应用新理论、新技术、新方法,尤其是信息技术和网络技术,建立数字化和结构化病案管理系统,并进一步完善病案信息的检索系统,统一医院内部软件,以此深入开发和利用病案信息资源,实现病案信息开发与利用的最大化,更好地服务于社会、医院和临床。
Medical records are extremely valuable medical information resources. Facing the progress of information technology, the medical record management patterns also change correspondingly. Staff members should change their thinking, update their concepts, attach importance to information feedback, enhance the level of information services, change from passive to active, and gradually change the traditional management mode, the medical record information from closed resources to open resources to establish a new model of medical record information management . At the same time, the application of new theories, new technologies and new methods, especially information technology and network technology, to establish a digital and structured medical record management system and further improve the retrieval system for medical record information and unify the hospital’s internal software so as to further develop and utilize medical records Information resources, to maximize the development and utilization of medical record information, to better serve the community, hospitals and clinics.