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口腔专科医院门(急)诊病案无纸化管理实践

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近年来,医院门(急)诊病案的数量逐渐增加,内容不断完善,应用场景日益丰富,凸显出传统纸质病案管理存在的存储空间占用大、查询利用效率低、损坏丢失概率高等问题。为了强化门(急)诊病案的统一管理和利用,北京大学口腔医院(以下简称医院)通过确立病案归档范围、建立病案归档流程、开展业务系统协同改造,搭建了电子病案归档系统,初步实现了门(急)诊病案的无纸化管理,进一步精简病案管理流程、提高了病案管理质量、节约了病案管理成本、提升了病案应用效率、丰富了病案应用场景。医院应更加全面地运用信息技术,强化信息化思维,推进运营决策的科学化、运行管理的高效化和患者服务的精准化。
Practice of Paperless Management of Outpatient(Emergency)Medical Records in Stomatology Hospital
In recent years,the number,content and application of outpatient(emergency)medical records are gradually increasing,improving and diverse,which is highlighting the problems of traditional paper based medical records management,such as large storage space occupancy,low query utilization efficiency,and high probability of damage and loss.In order to strengthen the unified management and utilization of outpatient(emergency)medical records,Peking University School and Hospital of Stomatology(hereinafter referred to as the hospital)established the scope of medical record archiving,established the medical record archiving process,carried out the collaborative transformation of business systems,and built an electronic medical records filing system.The paperless management of outpatient(emergency)medical records was initially achieved,further simplifying the medical record management process,improving the quality of medical record management,saving medical record management costs,improving the efficiency of medical record application,and enriching the application scenarios of medical records.Hospitals should comprehensively utilize information technology,strengthen information thinking,to promote scientific operational decision,efficient operational management,and precise patient services.

stomatological hospitaloutpatient(emergency)medical recordsinformed consentmedical record archivingpaperless managementdigital signature

陈怡帆、曹战强

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北京大学口腔医院信息中心,北京 100081

口腔医院 门(急)诊病案 知情同意书 病案归档 无纸化管理 数字签名

2024

中国卫生标准管理
《中国卫生标准管理》杂志社

中国卫生标准管理

影响因子:1.374
ISSN:1674-9316
年,卷(期):2024.15(23)