CAJ | 학술논문

结合某肿瘤专科医院病案随诊工作的实际情况，中长期恶性肿瘤患者随诊工作围绕不同的随诊种类进行，还需要随诊检索及与 HIS 系统的数据接口的支持。随诊的难点在于工作量巨大、随诊患者基本信息不准确、专题随诊差异性大造成信息难以共享等。通过建立专职随诊机构、建立随诊信息管理系统、规范随诊信息项、临床医师参加随诊工作等措施保证随诊的科学性。实施随诊信息化管理后有效提高工作效率，降低中长期患者失随率。开展随诊工作应合理配备病案信息管理专业技术人员，充分发挥其专业特长，紧密与临床医师协作，沟通随诊需求及课题设计思路，以便随诊人员充分理解及掌握问卷核心思想，最大限度的提高随诊数据质量。
결합모종류전과의원병안수진공작적실제정황，중장기악성종류환자수진공작위요불동적수진충류진행，환수요수진검색급여 HIS 계통적수거접구적지지。수진적난점재우공작량거대、수진환자기본신식불준학、전제수진차이성대조성신식난이공향등。통과건립전직수진궤구、건립수진신식관리계통、규범수진신식항、림상의사삼가수진공작등조시보증수진적과학성。실시수진신식화관리후유효제고공작효솔，강저중장기환자실수솔。개전수진공작응합리배비병안신식관리전업기술인원，충분발휘기전업특장，긴밀여림상의사협작，구통수진수구급과제설계사로，이편수진인원충분리해급장악문권핵심사상，최대한도적제고수진수거질량。
follow-up work of medium and long-term malignant tumor patients need follow-up retrieval and data interface with the HIS system support combined with the actual situation of a tumor hospital. Difficulties of follow-up are big workload; basic information is not accurate, difficult to share information, etc. Through the establishment of full-time follow-up institutions, establishing follow-up information management system, standardized follow-up, clinical physicians participate in follow-up work to ensure the scientific nature of the follow-up. The implementation of Information management can effectively improve work efficiency and reduce the rate of loss, at the same time should have medical record information management professionals, give full play to their professional expertise, collaborate with clinicians, communicate needs and design thought, so that follow-up staffs can fully understand and grasp the questionnaire core idea, maximum limit to improve data quality.