日间手术模式下病历管理制度问题分析与思考*

【摘 要】 病历管理制度是实现围手术期质量与安全的保证。针对日间手术病历缺陷，结合日间手术开展经验，提出应在符合制度初衷的前提下优化日间手术病历管理制度，完善日间手术病历内涵，并建立日间手术电子病历，以保障日间手术的质量与安全。

【关键词】 病历管理制度；日间手术；日间手术病历

中图分类号：R197.32        文献标识码：B

Analysis and Thinking of Medical Record Management System under the Mode of Ambulatory Surgery/YU Deliang，LIU Xiaonan.//Chinese Health Quality Management，2024，31（3）：25-27，36

Abstract The medical record management system is the core system to ensure the perioperative quality and safety. In view of the defects of the medical records of ambulatory surgery， combined with the experience of day surgery， it was proposed to optimize the medical record management system of ambulatory surgery under the premise of meeting the original intention of the system， improve the connotation of the medical record of ambulatory surgery， and establish the electronic medical record of day surgery， so as to ensure the medical quality and safety of ambulatory surgery， meet the needs of ambulatory surgery.

Key words Medical Record Management System；Ambulatory Surgery；Ambulatory Surgery Medical Record

Firstauthor's address First Affiliated Hospital of Air Force Military Medical University，Xi'an，Shaanxi，710032，China

1 研究背景

病历是医务人员在患者诊疗过程中形成的各种记录、报告等资料，可以细分为门（急）诊病历和住院病历［1］。（剩余5269字）