论文部分内容阅读
病历档案是人们在医院就医期间形成的全部医疗档案,即人们就医后由患者或家属陈述病情、病史以及医护人员对患者进行诊断、治疗、护理和愈后追踪过程实验室检查和其他特殊检查的报告等,它完整地记录了病人历次的检查、治疗和转归的全过程,以及与疾病有关的所有问题。病历档案从一定意义上讲也是临床医学的法定文件。因此,加强病历档案管理,有效地保护和利用病历档案,对医疗事业发展意义重大。下面,仅就如何加强病历档案管理工作谈点个人看法。
The medical records are all the medical records that people form during their hospital visits, that is, the patient’s or their family’s condition, medical history, and medical staff’s diagnosis, treatment, care and follow-up process of laboratory examination and other special inspection Report, etc. It completely records the entire process of examination, treatment and prognosis of the patients and all the problems related to the diseases. Medical records in a certain sense is also a statutory document of clinical medicine. Therefore, strengthening the management of medical record files and effectively protecting and utilizing the medical record files are of great significance to the development of medical services. Below, just talk about how to strengthen the management of medical records personal point of view.