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恶性肿瘤疾病随访工作的标准化管理

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病案随访是病案信息管理工作的重要组成部分,随访管理主要包括常规随访管理、科研随访管理以及随访的信息数据管理三部分.现阶段,随着医院对患者服务外延的扩大,对病案随访工作也同步提出了更高的要求.病案管理人员应根据不同的随访目的及需求,采用不同的随访技术及方法,合理利用患者信息资源,科学地积累随访数据资料,从而帮助临床医师全面系统地掌握各肿瘤疾病发生、发展规律,以及不同治疗手段的疗效和结局,达到提高医疗质量和发展医学科学的目的.文章以某肿瘤专科医院的肿瘤随访工作为例,结合病案随访信息化建设工作,探讨恶性肿瘤随访工作的重点内容、技术标准、工作指标及标准化管理模式等.
Standardized Management of Malignant Tumor Disease Follow-up Work
Medical records follow-up is an important part of medical records information management,which mainly includes routine follow-up management,scientific follow-up management and follow-up information data management.At present,with the extension of hospital services to patients,the follow-up work of medical records is also put forward higher requirements.Medical record managers should adopt different follow-up techniques and methods according to different follow-up purposes and needs,rationally utilize patient information resources,and scientifically accumulate follow-up data,so as to help clinicians comprehensively and systematically grasp the occurrence and development laws of various tumor diseases,as well as the efficacy and outcome of different treatment methods,so as to achieve the purpose of improving medical quality and developing medical science.This paper takes the follow-up work of a tumor hospital as an example,and discusses the key contents,technical standards,working indicators and standardized management mode of the follow-up work of malignant tumors in combination with the information construction of the follow-up work of medical records.

Malignant tumorPatient follow-upStandardized management

王凯鹏、霍宇艳、李书梅、徐小莉、刘怀戈、樊美娜

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中国医学科学院肿瘤医院病案室,北京市,100021

河北医科大学第四医院病案室,河北省,石家庄市,050000

首都医科大学附属安贞医院病案统计科,北京市,100011

中国医学科学院肿瘤医院深圳医院病案科,广东省,深圳市,518117

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恶性肿瘤 患者随访 标准化管理

2024

中国病案
中国医院协会

中国病案

CSTPCD
影响因子:1.197
ISSN:1672-2566
年,卷(期):2024.25(10)