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通过分析《医疗机构病历管理规定(2013年版)》,将其与2002版相比较,新规定更加明确了医疗机构的职责、对医护人员和病历管理人员的要求、增加了电子病历和封存病历的相关规定,并通过对医疗机构、医护人员、病历管理人员,病历无纸化、电子病历、大数据时代六个方面的思考,发现了各方面的相关问题,提出了相应的对策和建议,为推动医疗机构病历管理、推进电子病历的安全应用建设、在大数据时代下合理有效运用病历信息献计献策。
By analyzing the Regulations on the Management of Medical Records of Medical Institutions (2013 Edition) and comparing them with the 2002 edition, the new regulations make it clear that the responsibilities of medical institutions, the requirements for medical staff and medical records administrators, the increase of electronic medical records and the storage of medical records Relevant regulations, and through the medical institutions, medical staff, medical records management personnel, medical record paperless, electronic medical records, big data era of six aspects of thinking, found that all aspects of the relevant issues and put forward the corresponding countermeasures and suggestions for Promote medical records management in medical institutions, promote the construction of secure application of electronic medical records, and make rational and effective use of medical record information in the era of big data.