摘要:病历档案作为一种特殊的专门档案,它是反映和体现整个医疗过程的记录。因为其独特的价值,越来越受到人们的重视,然而其管理依然存在不足。面对当前病历档案管理存在的一些问题,如领导不重视、制度不健全、落实不到位、法制观念淡薄;传统的病案管理模式及流程存在的原始性漏洞;病历档案模糊不清以及病案书写质量不高;病案的鉴定缺乏专业的指导和组织;医院的病历本浪费等问题,本文在分析病历档案的概念本身所具有的特殊性的基础上提出病历的管理必须实施“前端控制思想”以及解决方法,也只有这样才能保持病案的原始记录性,保证病案的质量,为以后更好地利用提供前提条件和法律证据,而后提出本研究的意义。
[关键词]病历档案 病历档案管理 前端控制
Abstract:Medical records as a special specialized files, it reflects the entire process of medical records. Because of its unique value, it attracts increasing attention, but its management remains inadequate. Faced with the current problems of management on medical records, there are some problems: the leaders are neglected, the system is not complete, the implementation is not in place. legal concept is weak; there are primitive loopholes in traditional case-management model and the process; medical records are ambiguous and case-writing quality is not high; Identification of the cases is in the lack of professional guidance and organization; Hospital records is waste. Based on an analysis of the concept of unique medical records, the management of medical records must adapt to "the front control" and solution that maintain the historic record of cases and ensure the quality of the medical record in order to prepare for providing better use of community information and legal evidence, and then point out the significance of this study.
[Key words] Medical Record Management on Medical Record The front control
医院的中心任务是医疗工作,而反映和体现整个医疗过程的记录为病历档案---是人们向疾病作斗争的原始文献,完整地记录了病人历次检查、治疗、转归的全过程,以及与疾病有关的所有问题。由于其具有独特的利用价值,所以只有出色地做好病案管理工作才能体现病案信息在医院管理、医疗、预防、保健、科研、教学及民事诉讼中的重要地位和价值,才能充分利用它来为医疗、教学、科研服务。
本文在分析病历档案的概念本身所具有的特殊性的基础上提出病历的管理必须实施 “前端控制思想”。也只有这样才能保持病案的原始记录性,保证病案的质量,为以后更好地利用提供前提条件和法律证据,本文主要从病案管理中存在的问题进行分析,然后提出相应的解决对策和方法,并阐明所提出的前端控制在病案管理中的意义。