CAJ | 학술논문

目的尝试应用光盘扫描技术对我院老旧纸质病案进行现代化管理.方法将所有已归档的死亡病案进行扫描,共有病案约26425份.扫描病案的内容为:首页、出院记录、住院病历、首次病程记录、病程记录、知情同意书、医嘱单、辅助检查报告单、医学影像检查资料、病理报告单、体温单.结果已将所有归档的死亡病案扫描,并刻录制作成光盘.结论⑴改变了病案的阅览方式,方便了病案的复印工作;⑵增加了病案的安全性,减少了病案的磨损和丢失;⑶采用密集架管理,节省了存储空间;⑷光盘保留了原件的历史风貌,能够长期安全保存;⑸与医院HIS系统接连,可以在医院范围内共享医疗数据.
목적상시응용광반소묘기술대아원로구지질병안진행현대화관리.방법장소유이귀당적사망병안진행소묘,공유병안약26425빈.소묘병안적내용위:수혈、출원기록、주원병력、수차병정기록、병정기록、지정동의서、의촉단、보조검사보고단、의학영상검사자료、병리보고단、체온단.결과이장소유귀당적사망병안소묘,병각록제작성광반.결론⑴개변료병안적열람방식,방편료병안적복인공작;⑵증가료병안적안전성,감소료병안적마손화주실;⑶채용밀집가관리,절성료존저공간;⑷광반보류료원건적역사풍모,능구장기안전보존;⑸여의원HIS계통접련,가이재의원범위내공향의료수거.
Objective Trying to apply optical scanning technology to modernize the older paper medical records in our hospital management. Methods All archived death medical records scanning, there are medical records about 26425. Scan the contents of medical records: Home, hospital records, medical records, course records, course records for the first time, informed consent, order form, supplementary information inspection reports, medical imaging, pathology reports, temperature. Results All archived death medical records have been scanned, and burn a CD. Conclusion ⑴Changed the way medical records access, facilitates the reproduction of medical records; ⑵Increase the security of medical records, reducing wear and loss of medical records; ⑶An intensive management, saving storage space; ⑷Disc of original historical style, the long-term safe storage; ⑸Back-to-back with the hospital HIS systems, medical data can be shared within the hospital.