网络环境下病历档案信息管理和服务.docVIP

网络环境下病历档案信息管理和服务 　　[摘要] 随着计算机、网络通信技术在医院的广泛深入应用,医院病历档案管信息理与服务也进入了管理自动化、资源数字化、信息传递网络化的新阶段。在网络环境下,医院病历档案室应如何充分利用计算机和网络技术,搞好病历档案信息管理与服务,满足不同利用者需求,推动医院病历档案事业的发展。本文从网络环境下,病历档案管理与服务特点、病历档案信息管理与服务措施、病历档案信息服务应注意的问题等方面进行叙述,认为网络环境下病历档案信息管理与服务,便利、高效、优质,是当今和将来的发展方向。 　　[关键词] 网络环境;病历档案;管理与服务 　　[中图分类号] R197.322[文献标识码] C [文章编号] 1673-7210(2010)06(b)-109-03 　　 　　Medical records management and service under the network environment 　　LI Weiming1, WANG Shaijun2, ZHANG Yajin1, ZENG Yuhe1 　　(1.Huizhou Central Peoples Hospital, Guangdong Province, Huizhou516001, China; 2.Huizhou Branch, Guangdong Mobile Co., Ltd., Huizhou 516001, China) 　　[Abstract] With the extensive applications in computer and network communication technology in the hospital, the hospital medical records management and service have entered a new stage of management automation, resource digitization and transmission network. Under the network environment, the hospital medical records department should make full use of computer and network technology as well as improve information management and medical records services to meet the different needs of customers and promote the development of the hospital medical records. This paper explores, under the network environment, the characteristics of medical records management and service, medical archival management and services and what should be paid attention to in medical archival services. It concludes that medical records management and services under the network environment are convenient and efficient and high-quality, which directs the way for current and future development. 　　[Key words] Network environment; Medical archival; Management and services 　　 　　随着计算机、网络通信等技术在医院广泛深入应用,一些中大医院在医院信息系统(HIS)应用到临床、医技、药剂等科室与患者医疗相关的各个环节后,医学影像系统(PCAS)、检验系统(LIS)相继应用,并对HIS的功能进行扩充升级及与PCAS、LIS等进行集成互联,开发应用互联网环境下集文字、符号、图形、声像等于一体的电子病历档案系统(简称电子病案 EMR)。虽然目前处于电子病历档案与纸质病历档案并存双轨制应用阶段,但对病历档案的管理和服务产生了深刻的影响。本文就网络环境下,对病历档案信息的管理与服务进行探讨。 　　1 传统的病历档案管理与服务 　　1.1 管理方面 　　传统的病历档案是以纸质为载体书写和储存,数