医院文书档案管理和利用.docVIP

医院文书档案管理和利用 　　doi：10.3969/j.issn.1007-614x.2014.10.105 　　摘 要 医院文书档案管理是医院管理的重要部分，目前，随着医院的发展，特别是信息技术的发展，提高了医院文书档案管理的水平。医院文书是记录患者诊疗过程的重要依据，特别是随着医疗纠纷的增多，医院文书成为法律的重要依据，随着医疗举证倒置的实施，医院文书的完整性显得更为重要。另外，随着科研工作的逐步加强，医院文书作为诊治疾病的原始资料，对疾病的诊断回顾有着重要的意义。随着网络的发展，档案信息作为一种资源，为医院发展提供真实、有效的档案信息，医院文书在医疗救护、学术探讨、学术研究和医疗纠纷方面发挥着重要作用。为此，笔者结合国内外有关文献和医院工作实际对医院文书档案管理和利用进行阐述。 　　关键词 医院文书 档案信息 档案管理 资源 利用 　　Management and utilization of hospital archives 　　Zhang Aizeng 　　The Traditional Chinese Medicine of Zhumadian City，Henan 463000 　　Abstract The hospital archives management is an important part of hospital management.At present，the hospital archives management level is improved at the same time with the development of the hospital，especially the development of information technology.Hospital archives is an important basis for the records of patients with the process of diagnosis and treatment，it has become an important legal basis especially with the increasement of medical disputes.With the implementation of the inversion of evidential burden，the integrity of hospital archives is more important.In addition，the hospital files as the original data of diagnosis and treatment of diseases is important for the review of diagnosis for the disease along with the scientific research work to strengthen gradually.With the development of network，the archive information can provide real，effective information for the development of hospital as a resource.It play an important role in medical，academic research，academic research and medical disputes of hospital archives.Therefore，the author expounds the management and utilization of hospital archives combined with the work in hospital and the related literature at home and abroad. 　　Key words Hospital archives；The file information；File management；Resources；Use 　　医院文书档案管理是医院管理的重要部分。目前，随着医院的发展，特别是信息技术的发展，医院文书档案管理的水平也提高了。医院文书是记录者诊疗过程的重要依据[1]，特别是随着医疗纠纷的增多，医院文书成为法律的重要依据[2]，随着医疗举证倒置的实施，医院文书的完整性显得更为重要。另外，随着科研工作的逐步加强，医院文书作为诊治疾病的原始资料，对疾病的诊断回顾有着重要的意义。随着网络的发展，档