论文部分内容阅读
病案管理是一项科学性、技术性较强的工作,必须采取一系列科学方法进行管理.以满足医疗、教学、科研的需要。我院于1992年扩建以来。单设了病案统计室,病案管理工作建立了一整套的管理制度。从病房病案的书写、收集、整理、登记到疾病的分类、偏目和登记卡片的建立,以及医疗统计报表工作的开展,逐步走向正规。现将工作体会介绍如下。一、病案书写质量的要求1、院领导把病案书写工作质量作为主要项目。
Medical record management is a scientific and technical work. It must be managed by a series of scientific methods to meet the needs of medical, teaching, and scientific research. Our hospital has expanded since 1992. The medical statistics office was set up alone, and the medical record management work established a set of management systems. From writing, collecting, sorting and registering medical records in wards to the classification of diseases, establishment of gazetteers, and the establishment of registration cards, and the development of medical statistical reports, they gradually became formal. The work experience is described below. First, the requirements for the writing quality of the medical record 1. The leadership of the hospital takes the quality of the written case work as the main item.