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日间手术模式下病历管理制度问题分析与思考

Analysis and Thinking of Medical Record Management System under the Mode of Ambulatory Surgery

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病历管理制度是实现围手术期质量与安全的保证.针对日间手术病历缺陷,结合日间手术开展经验,提出应在符合制度初衷的前提下优化日间手术病历管理制度,完善日间手术病历内涵,并建立日间手术电子病历,以保障日间手术的质量与安全.
The medical record management system is the core system to ensure the perioperative quality and safety.In view of the defects of the medical records of ambulatory surgery,combined with the experience of day surgery,it was proposed to optimize the medical record management system of ambulatory surgery under the premise of meeting the o-riginal intention of the system,improve the connotation of the medical record of ambulatory surgery,and establish the e-lectronic medical record of day surgery,so as to ensure the medical quality and safety of ambulatory surgery,meet the needs of ambulatory surgery.

Medical Record Management SystemAmbulatory SurgeryAmbulatory Surgery Medical Record

俞德梁、刘小南

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空军军医大学第一附属医院 陕西 西安 710032

病历管理制度 日间手术 日间手术病历

陕西省软科学研究计划西京医院学科助推计划(2019)

2022KRM184XJZT19X11

2024

中国卫生质量管理
中国医院协会,陕西省人民医院

中国卫生质量管理

CSTPCD
影响因子:1.091
ISSN:1006-7515
年,卷(期):2024.31(3)
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