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随着医院管理科学的发展,微机已被广泛应用于医院的各个领域。减少手工操作,实行微机管理,是病案管理走上科学化、规范化、正规化道路的必要手段。然而,使用微机管理病案,不仅是病案室自己的工作,而且需要医院有关部门的紧密配合才能完成。以下结合我院的实际谈谈做好病案微机管理的前提条件。 1 住院处 在我院,住院处是住院病案的创始地,也是病人出院时病案的收集地。它对病案微机管理应做好以下工作: 1.1 住院病案采用一号制 病人第一次入院,住院处按顺序编写住院号,并注明在该病人的门诊病案上,做为此次住院的病案号。病人再入院时,从门诊病案上取得原住院号,不另给新号。对门诊病案上未注明者,应设法查询原住院号。 1.2 确保病案首页上一般项目内容填写正确齐全。 1.3 住院处需每日登记(住院病人入院登记表)内容包括:病人姓名,性别,出生年、月、日,年龄,职业,工作单位,入院科别,住院号和费用支付形式(公费、劳保、医疗保险、自费及其它)等。
With the development of hospital management science, microcomputers have been widely used in various fields of hospitals. Reducing manual operations and implementing computer management are the necessary means for medical record management to embark on a scientific, standardized, and regularized road. However, the use of microcomputers to manage medical records is not only the work of the case itself, but also requires the close cooperation of relevant departments of the hospital. The following combination of the actual situation in our hospital to talk about the premise of good computer management of medical records. 1 Inpatient Department In our hospital, the in-hospitalization office is the origin of the inpatient medical record, and is also the collection site for the patient’s medical records when they leave the hospital. It should do the following work for the computer management of medical records: 1.1 Inpatient medical records adopt the No. 1 system for the first time, and the hospitalization department prepares the hospitalization number in order and indicates the patient’s outpatient medical record as the medical record of this hospitalization. number. When the patient was re-admitted to the hospital, the original hospital number was obtained from the outpatient medical record and no new number was given. For those who do not indicate on the outpatient medical record, they should try to find out the original hospital number. 1.2 Ensure that the contents of the general items on the front page of the medical record are filled in correctly and completely. 1.3 The inpatient office is required to register on a daily basis (inpatient admission registration form) including: patient name, gender, birth year, month, day, age, occupation, work unit, admissions department, hospitalization number and fee payment form (public expense, labor insurance) , medical insurance, own expenses and other) and so on.