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病案号唯一性管理的探讨 预览

Discussion on the unique management of medicalrecord number
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摘要 病案号唯一是指同一患者在某院就医使用唯一编号,历次门诊和住院资料都以同一编号保存,它保证了患者在医院就诊资料的完整性和连续性,是日后查找患者病案资料的唯一途径。病案号唯一是法律法规的要求、满足患者诊疗的需求及患者诊疗信息整合的需要。影响病案号唯一的原因主要是:无唯一号管理标准;基本信息管理不规范;医务人员责任心不强;患者对病案号不重视;缺乏对异常病案号的管理。为保障患者病案号唯一,要制定唯一号管理的标准,坚持基本信息规范化管理,提高医务人员的责任意识,加强对异常病案号的管理。 The medical record number only refers to the unique number used by the same patient in a hospital,all previous outpatient and inpatient information are kept in the same number,it ensures the integrity and continuity of the patient's medical records in the hospital,it is the only way to find the patient's medical records in the future.The only medical record number is the requirement of laws and regulations,meeting the needs of patients'diagnosis and treatment,and integrating the information of patients'diagnosis and treatment.The only reason that affects the medical record number is that there is no single management standard,the basic information management is not standardized,the responsibility of medical staff is not strong,patients do not attach importance to the medical record number,lack of management of abnormal medical record number.In order to guarantee the unique number of patients'medical records,it is necessary to formulate the standard of the unique number management,adhere to the standardized management of basic information,improve the sense of responsibility of medical staff,and strengthen the management of abnormal number of medical records.
作者 袁萍 甄玲 刘吉羊 Yuan Ping;Zhen Ling;Liu Jiyang(Department of Medical Record Management,Xiaogan Central Hospital(Xiaogan Hospital Affiliated toWuhan University of Science and Technology),Xiaogan,Hubei,432000China)
机构地区 孝感市中心医院
出处 《当代医学》 2019年第24期134-135,共2页 Contemporary Medicine
关键词 病案号 唯一性 管理 Medical record number Uniqueness Management
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