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门诊病案是医院病案的一个重要组成部分,也是医院整体质量的一个重要组成部分。然而,门诊病案管理却长期被忽视。因此,有必要尽快加强和研究门诊病案管理问题。一、门诊病案与住院病案的同质性:主要有以下几点:(1)都是记录病人所患疾病发生、发展、诊疗经过及转归。(2)都是医生工作质量,医院技术水平的集中反映。(3)及时性、准确性、完整性、整洁性是记录的基本要求。(4)都是医院的信息源,能够为医院的管理、统计、医学、教育、科研服务。二、门诊病案的特点:(1)门诊病案记录的是在
Outpatient medical records are an important part of hospital medical records and an important part of the overall hospital quality. However, outpatient medical record management has long been neglected. Therefore, it is necessary to strengthen and study the management of outpatient medical records as soon as possible. 1. The homogeneity of outpatient medical records and inpatient medical records: The following are the main points: (1) All patients are recorded for the occurrence, development, diagnosis and treatment of the disease and their outcome. (2) Both are the quality of doctors’ work and the concentration of hospital technical level. (3) Timeliness, accuracy, completeness, and cleanliness are the basic requirements for records. (4) Both are hospital information sources and can provide services for hospital management, statistics, medicine, education, and scientific research. Second, the characteristics of outpatient medical records: (1) Outpatient medical record is in