| 摘要: |
| 目的 调查上海市医院的病案信息化管理情况，了解当前上海市医院在病案的信息化方面的管理现状，发现其中存在的问题，为进一步加强上海医院病案信息化管理提出相应建议。方法 采用问卷调查与实地访谈相结合的方法，对上海69家医院进行现场问卷调查，其中三级医院23家，二级医院46家。结果 目前病案管理存在信息系统开发功能不完善和病案信息交流封闭等问题。结论 可以通过建立“电子病案系统”，同时推广和应用电子病案，提高医院病案信息化管理水平。 |
| 关键词: 病案 管理 信息化 |
| DOI： |
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| 基金项目: |
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| An Investigation and Analysis on Hospital Medical Record Information of 69 Hospitals in Shanghai |
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| Abstract: |
Objective
To investigate the Shanghai hospital medical record information management situation, found that there were problems, in order to further strengthen the hospital medical record information management in Shanghai put forward the corresponding suggestions. Methods Using questionnaire and on-the-spot interview method to 69 hospitals of Shanghai on-site questionnaire survey, including 23 tertiary hospital, 46 secondary hospital. Results The medical record management information system development and the function is not perfect and closed medical record information exchanges. Conclusion It should be established the electronic medical record system, combined with the promotion and application of electronic medical record，to improve the level of the hospital medical record information management. |
| Key words: medical record, management, informatization |
