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病案作为珍贵的医学资料使用范围日益广泛,保持病案可获得性更显重要。本文通过分析某二级综合医院病案管理工作中存在的具体问题,从病案的归档、存储、借阅三方面加强库房管理提高病案的可获得性。采用了以下措施包括建立科室归档率通报制度,完善病案回收监控体系,达到出院病案及时归档;加强病案库房管理,健全库房管理制度,成立病案检查小组,达到安全、有序、科学存储病案;加强对病案借阅环节的管理,健全病案借阅制度,建立抽查制,达到病案流通中的“零”丢失;采用数字化病案管理模式,应用扫描、条形码技术等,能够有效实现保持病案可获得性这一目的。
As medical records are increasingly used as precious medical information, it is even more important to maintain the accessibility of medical records. This article analyzes the specific problems existing in the medical records management in a second-level general hospital and enhances the availability of the medical records from the aspects of archiving, storing and borrowing medical records. Adopted the following measures including the establishment of department filing rate notification system, improve the medical record recovery monitoring system, to achieve timely discharge of medical records; strengthen the management of medical records warehouse, improve the warehouse management system, the establishment of medical record inspection team to achieve safe, orderly and scientific storage of medical records; The management of the borrowing of medical records, improve the system of medical records borrowing, the establishment of random checks, to achieve “zero” loss in the medical record circulation; the use of digital medical record management, application scanning, bar code technology, can effectively achieve the accessibility of medical records First, the purpose.