摘要
医务人员在临床工作中记录患者疾病的发生、演变、诊断质量、治疗措施及其最终结果的原始档案被称为医案。同时医案也是医疗保险、判定法律责任、解决医疗纠纷的重要依据。因此,应重视病案复印现状,对病案复印现状中存在的问题进行详细分析,同时给予解决措施如建立健全的现代医院管理制度、转变服务理念、对病案复印流程进行优化、加强宣传、对基础设备进行完善及增设快递服务等,对病案复印现状中存在的问题进行改进,满足患者的多样化需求,同时可加强病案工作人员的服务意识,提高工作效率,有利于促进医患关系的和谐,对临床具有重要意义。同时分析国外及国内病案复印的研究进展,为病案复印的发展提供新的方向,同时从患者的角度出发,将服务内涵不断延伸。因此,本研究将探讨病案复印现状及研究进展,以期为患者快捷、方便地提供病案,同时为临床病案工作提供依据。
The original files that medical staff record the occurrence,evolution,diagnosis quality,treatment measures and final results of patients'diseases in clinical work are called medical records.At the same time,medical records are also an important basis for medical insurance,determination of legal liability,and resolution of medical disputes.Therefore,attention should be paid to the current situation of medical record copying,and a detailed analysis of the problems existing in the current situation of medical record copying should be carried out.At the same time,solutions are given,such as establishing a sound modern hospital management system,changing service concepts,optimizing the process of copying medical records,strengthening publicity,improving basic equipment and adding express services.The problems existing in the current situation of medical record copying were improved to meet the diverse needs of patients.At the same time,it can strengthen the service awareness of medical record staff and improve work efficiency,which is conducive to promoting the harmony of doctor-patient relationship,and has important clinical significance,analyzes the research progress of medical record copying at home and abroad,and provides a new direction for the development of medical record copying.At the same time,from the perspective of patients,the service connotation will be continuously extended.Therefore,this study will discuss the current situation and research progress of medical record copying,in order to provide patients with medical records quickly and conveniently,and provide a basis for clinical medical record work.
作者
李桂荣
张元
隗和红
LI Guirong;ZHANG Yuan;WEI Hehong(Medical Record Room,Miyun District Hospital,Beijing,101599 China;Medical Record Room,Peking University Sixth Hospital,Beijing,100083 China)
出处
《中国卫生产业》
2022年第17期240-243,共4页
China Health Industry
关键词
病案
复印
研究进展
现状
改进措施
Medical records
Copy
Research progress
status quo
Improvement measares
