北京博爱医院病案室是与医院前身中国康复研究中心于1988-10-28一同建立的。科室共分为三个部分:包括挂号室,统计室,病案室。
挂号室承担全院科室挂号、建案、索引录入工作,挂号主要包括现场挂号,预约挂号(114预约挂号,网上预约挂号,微信预约挂号),同时负责回收整理急诊留观病历。
统计室负责全院的统计工作,包括制作医疗日报、月报、季报、年报、人力资源、设备资源调查表等,死亡卡统计上报工作,每年制作一册全院综合统计汇编。
病案管理,病案采取一号分开式管理,住院病案室主要负责病案的回收、整理、借阅、质检工作。
科室人员主要由病案相关专业毕业人员组成,并包括一名博士及两名硕士,能过完成上一级部门医务处布置全部工作,能过配合其他部门完成临时性统计数据提供等工作。
科室由建科初期的手工管理,逐步实现了病案的信息化管理,通过医院的HIS的病案模块完成挂号及预约工作,患者的诊疗信息除去知情同意书全部实现电子化,统计数据收集整理分析报送基本实现网络化,能及时准确收集上报各种信息,完成医院交给工作。
The medical record room of Beijing Bo'ai Hospital was established with the hospital predecessor China Rehabilitation Research Center in 1988-10-28. The Department is divided into three parts: the registration room, the statistics room, the medical record room.
The registration room is responsible for the registration, case establishment and index entry of the whole hospital. Registration mainly includes on-site registration, appointment registration (114 appointment registration, online appointment registration, WeChat appointment registration), and at the same time, it is responsible for recovering and finishing the emergency medical records.
The statistics office is responsible for the statistical work of the whole hospital, including making medical daily reports, monthly reports, quarterly reports, annual reports, human resources, equipment resources questionnaire, etc., and reports the death card statistics.
Medical record management, medical records to take a separate management, inpatient case room mainly responsible for the recovery of medical records, collation, borrowing, quality inspection work.
The Department staff is mainly composed of medical record related professionals, including a Ph.D. and two masters. They can finish all the work of the medical department at the upper level department, and cooperate with other departments to complete the temporary statistical data provision.
The Department from manual management of early stage, gradually realize the information management of medical records, medical records through the hospital HIS module to complete the registration and appointment work, patient information from informed consent to achieve full electronic data collection, statistical analysis to the basic realization of the network, can collect various information timely and accurate reporting, complete the hospital to work.
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