论文部分内容阅读
病案是医疗活动的记录,也是医疗信息的主要来源。随着社会信息化步伐的加快,对病案也提出了更深层次的服务要求。病案广泛应用于临床的医教研,医院的经营管理,医疗的纠纷和法律案件,医疗保险服务,疾病的预防和控制,医疗服务质量,医疗政策的制定和调整等方面。强化病案为医疗服务的观念,使病案的价值得到充分体现,只有正确的认识病案在医疗方面的价值,才能将病案更好的服务于医疗应用。
The medical record is a record of medical activities and the main source of medical information. With the acceleration of the pace of social informatization, a deeper level of service requirements have also been proposed for medical records. Medical records are widely used in clinical teaching and research, hospital management, medical disputes and legal cases, medical insurance services, disease prevention and control, medical service quality, medical policy formulation and adjustment. Strengthening the concept of medical records as a medical service enables the value of medical records to be fully reflected. Only by correctly understanding the value of medical records in terms of medical treatment can we better serve medical records for medical applications.