摘要
作为医疗质量管理的核心环节,病案管理在医疗信息化背景下正经历从传统档案存储向医疗数据资产转化的深刻变革,其管理效能直接影响医疗机构的运营质量。基于三甲医院实践,构建融合电子签名技术的病案无纸化系统,涵盖4大功能平台与1个子系统,系统阐释架构设计与实施路径,实现病案全流程管理的数字化转型。自系统上线后,2023年10月1日—2024年10月8日累计出院病案96 460份,电子归档率达到70.92%,病案平均归档天数由7天缩短到5天,累计耗材成本节省约45万元。实践表明该系统显著提升归档效率与数据质量,但电子签名认证体系完善度不足及异构系统数据对接等问题仍需突破。建议通过强化数字认证体系、构建智能采集平台等举措,为推进病案管理现代化建设提供理论支撑与实践范式。
As the core link of medical quality management,medical record management is undergoing profound changes from traditional file storage to medical data asset transformation under the background of medical informatization,and its management efficiency directly affects the operation quality of medical institutions.Based on the practice of tertiary hospitals,this study constructs a paperless system of medical records integrating electronic signature technology,covering four functional platforms and one subsystem.It systematically explains the architecture design and implementation path,and realizes the digital transformation of the whole process management of medical records.Since the system was launched,a total of 96,460 discharge medical records have been collected from October 1,2023 to October 8,2024,with an electronic filing rate of 70.92%.The average filing days for medical records have been shortened from 7 days to 5 days,and the cumulative consumables cost has been saved by approximately RMB 450,000.The practice shows that the system significantly improves the archiving efficiency and data quality,but the problems such as the lack of electronic signature authentication system and the data docking of heterogeneous systems still need to be broken through.It is suggested to provide theoretical support and practical paradigm for promoting the modernization of medical record management by strengthening the digital authentication system and building an intelligent acquisition platform.
作者
周澎洋
蒲旭虹
刘莉莉
Zhou Pengyang;Pu Xuhong;Liu Lili(Gansu Provincial Hospital of Traditional Chinese Medicine,Lanzhou 730050,Gansu Province,China;不详)
出处
《中国病案》
2025年第9期30-32,共3页
Chinese Medical Record
基金
甘肃省科技计划项目(联合科研基金)(24JRRA904)。
关键词
无纸化
病案归档
电子签名
电子病历
Paperless
Medical record filing
Electronic signature
Electronic medical record
