Construction and practice of paperless management in medical records automatic archiving
10.3760/cma.j.cn111325-20210604-00510
- VernacularTitle:病案自动归档无纸化管理建设实践
- Author:
Shengrong ZHU
1
;
Wei LI
;
Chen ZHANG
;
Wenhuan LI
;
Hong JI
Author Information
1. 北京大学第三医院信息管理与大数据中心 100191
- Keywords:
Information management;
Medical record management;
Paperless;
Automatic archiving
- From:
Chinese Journal of Hospital Administration
2021;37(11):944-948
- CountryChina
- Language:Chinese
-
Abstract:
As medical record management is key to hospital management, a hospital introduced paperless practice of automatic archiving in the following practices. Clarification and identification of the scope of business system transformation, establishment of an architecture integrating various business systems, integration platform, hospital data center, archiving system and certification authority, creation of three automatic archiving processes: initial archiving, late return archiving and modification archiving, for refined management of the review and tracking of archived medical records. Thanks to this paperless management, the automatic archiving rate was as high as 95.95%for medical records, 96.47%for laboratory reports and 99.58%for medical orders respectively. A full-process and whole-cycle informationized closed loop management was achieved for the collection, archiving, review and utilization of medical records, substantially upgrading hospital informationization and medical record management.
