广州医药 ›› 2020, Vol. 51 ›› Issue (6): 109-112.DOI: 10.3969/j.issn.1000-8535.2020.06.025

• 论著 • 上一篇    下一篇

某新冠肺炎定点医院疫情期间病历管理方案的探索

于磊, 钟小兰, 曹天生   

  1. 广州市花都区人民医院(广州 510800)
  • 收稿日期:2020-05-28 出版日期:2020-11-20 发布日期:2021-11-28
  • 通讯作者: 曹天生,E-mail:caotiansheng2088@sina.com

Exploration of medical record management plan during COVID-19 epidemic situation in a designated hospital

YU Lei, ZHONG Xiaolan, CAO Tiansheng   

  1. Huadu District People's Hospital of Guangzhou, Guangzhou 510800,China
  • Received:2020-05-28 Online:2020-11-20 Published:2021-11-28

摘要: 新型冠状病毒肺炎是一种新发的急性呼吸道疾病,如何准确、完整、及时的记录好新冠肺炎患者的病历信息,为医学研究提供科学的依据是医院病案管理统计的工作重点。本文结合国家相关的规定和某新冠肺炎定点救治医院疫情防控工作经验,提出针对新冠肺炎病历的管理方案,包含病历的书写、编码、运行管理三方面,配合医院做好疫情防控工作的同时妥善记录好新冠肺炎患者病历信息。

关键词: 新冠肺炎, 病历书写, 病历管理, 编码

Abstract: Coronavirus disease 2019 is a new type of acute respiratory disease. Recording accurately, completely and timely the medical records of patients with COVID-19 and providing a scientific basis for medical research are the focus of the medical records management statistics. This paper proposes a management plan including writing, coding, and operation management for COVID-19 medical records, combining with the relevant national regulations and a COVID-19 designated hospital's experiences of epidemic prevention and control. This management plan cooperates with the hospital to do epidemic prevention and control work, and properly recordes the medical records of COVID-19 patients.

Key words: Coronavirus Disease 2019, Medical Records Writing, Medical Record Management, Code