摘要
目的 探讨病案管理的重要性。方法 对我院 2 0 0 3年调阅病案资料的用途进行分析。结果 病案为医疗保险机构监督审核医疗费用使用情况、医疗保险核保赔付及执法部门提供有价值的原始资料 ,对诊断不明或未治愈病人转院治疗提供有参考价值的医学资料 ,为统计分析各病种的治疗指标及合理用药情况 ,提高医疗服务质量 ,同时还为教学、医学科研提供可靠、科学的原始资料 ;医院管理机构利用病案信息对医院未来发展进行预测 ,并制定发展目标。结论病案资料客观、真实地记录了病人住院期间的诊疗情况 ,为医院保险机构、执法部门、医学科研、教学及医院的发展提供有价值的原始信息资料。
Objective To explore the importance of medical record management. Methods The purpose of medical record lending in our hospital i n 2003 was analyzed.Results medical record offered valuable original data for medic al insurance orga nization and judicial department, offered valuable medical information for patie nts without final diagnosis or patients who wanted to transfer to another hospit al. it was benefit to analyzing the treatment of each diseases and rational use of drug for improving the quality of treatment. in the same time, it offered the dependaable and scientific date for teaching and medical researching. Based on the medical record, the managers could forecast the hospital's future and consti tuted the hospital's aim. Conclusions medical Record data was objective record of pat ients during the time in hospital. It also offered much worthy original data for medical insurance or ganization, judicial department, medical research and teaching. It was benefit t o the developing of a hospital.
出处
《实用全科医学》
2005年第1期89-90,共2页
Applied Journal Of General Practice
