Practice of paperless management of medical records in a hospital
10.3760/cma.j.cn111325-20231205-00376
- VernacularTitle:某院病案无纸化管理实践
- Author:
Ling HONG
1
;
Weifeng YING
;
Qin SUN
;
Jianhong JIANG
;
Liangfeng ZHU
Author Information
1. 浙江省嘉兴市第一医院质量管理部，嘉兴 314000
- Keywords:
Medical records systems, computerized;
Medical record management;
Paperless;
Electronic signature;
Archive process
- From:
Chinese Journal of Hospital Administration
2024;40(5):400-404
- CountryChina
- Language:Chinese
-
Abstract:
Paperless management of medical records is of great significance in promoting refined hospital management. Driven by national policies and the development of information technology in medical institutions, paperless medical records have become an inevitable trend in the development of medical records. However, at present, there were still a large number of medical record data in China that cannot be digitized or directly uploaded to hospital electronic medical record systems. Since 2019, the First Hospital of Jiaxing has launched a paperless medical record construction project and established a paperless medical record management system, forming a closed-loop management system for the entire process of medical record collection, archiving, storage, management, and utilization. By the end of 2021, paperless of medical records in all departments had been achieved, electronic signatures had been fully implemented, and paperless versions of reports of standalone equipment, high-value consumables barcodes, surgical anesthesia related documents, and outsourced inspection reports had been achieved, with a paperless rate of 98.5%. Through paperless management of medical records, the supervision of medical record quality and medical quality has been strengthened, operating costs have been reduced and work efficiency has been improved. At the same time, this has provided convenience for medical personnel to access medical record information and applicate of the data, and has effectively improved the hospital′s level of refined management. It can provide reference for paperless management of medical records in other medical institutions.
