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一、引言 住院病人的诊断、治疗和其他医疗服务构成了医院医疗活动的主体。收集、整理和分析住院病人的信息不仅能了解医院的运行状况,更重要的是能够对医院的医疗水平、医疗服务效率等方面进行科学的评价。但住院病人的信息种类多,数量大,要完全地收集起来是不现实的。从住院病人信息收集过程的可操作性角度来看,建立住院病人基本信息集是可取的,同样能满足许多医院管理工作的需要,国外的做法也证实了这一点。[2][4]
I. INTRODUCTION The diagnosis, treatment and other medical services of inpatients constitute the main body of hospital medical activities. Collecting, arranging and analyzing inpatient information can not only understand the operating status of the hospital, but more importantly, it can scientifically evaluate the hospital’s medical level and medical service efficiency. However, the inpatients have a large variety of information, and it is unrealistic to collect them completely. From the point of view of the operability of the inpatient information collection process, it is desirable to establish a basic information set for inpatients, which can also meet the needs of many hospital management tasks. Foreign practices have also confirmed this. [2][4]