Research On The Evolution And Development Of Medical Records Management Pattern

Medical records are the crystallization of clinical thinking and experience of medical staff.The development of medical records management has a long history both abroad and in China.Modern medical record archives management in China has gone through nearly a hundred years.Summarizing the development history of medical records management in the past 100 years and summarizing the development law of medical records management is of great importance to grasp the historical context of the development of medical records management and the development trend of medical records management.At the same time,for the medical and health administrative departments to formulate laws and regulations for the management of medical records,medical institutions managers and medical records management departments to formulate regulations for the management of medical records,medical personnel attach importance to the production and operation of medical records,as well as specific to each medical record archivist to carry out the work of medical records and scientific management of medical records.Archives are of great significance.Medical records management is an integral part of the management of medical institutions.In 1921,Peking Union Medical College Hospital established the first medical record room in the history of modem medical records management,opening a new chapter of centralized and unified management of medical records in China.According to the theory of archives management,the management of medical records is divided into two main parts:entity management and information management.Evolution and development of medical record archives management has been carried out around the entity management and information management of medical record archives.The author combines the main contents of medical record file management with specific events related to medical record file management,and divides the history of medical record file management in the past hundred years from 1921 to now into four main stages for the first time.In the history of medical record archives management over the past 100 years,the object of medical record archives management,the relative change of the process,content and task of medical record archives management are unchanged.Managing the medical records,writing the medical records,building the medical records and using the medical records well have their own clear management contents,corresponding to different management stages and management patterns.Based on the evolution and development of the content of medical record archives management,combining with the theory of information management development stage,the theory of archives management and the theory of document life cycle,as well as the actua]application of information technology in the management of medical record archives,the author summarizes four kinds of medical record archives management patterns corresponding to the four stages.This paper mainly combs the research results of medical records management at home and abroad,demonstrates the necessity of research,and elaborates the research methods,research ideas and research significance involved.On the basis of defining the concepts of medical record file,medical record file management and medical record file management pattern,the author clarifies the definition of medical record file management pattern,and analyses the relationship between the contents of four stages of medical record file management and medical record file management pattern.The author elaborates the specific application of information management development stage theory,archives management theory,document life cycle theory,whole process management theory,data management theory and archives pattern management theory in each chapter.The author defines the historical period of medical records management from 1921 to 1981 as the stage of entity management of medical records.In this stage,medical records can be well managed through collection,collation,identification,storage and supply.The establishment of a medical record room,the hospital to achieve centralized and unified management of medical records,medical staff to provide the entity of medical records.At this stage,all business processes of medical records management are carried out in the medical records room.At this stage,the main task of medical records management is to manage the medical records through scientific management of the entity of medical records.The links before and after collection,collation,appraisal,storage and supply are interrelated and interacted,so as to realize the entity management pattern of managing medical record files well.The entity management pattern of medical records provides entity utilization services for medical business and scientific research in medical institutions.This process reflects the role of medical record files for reference,reference and vouchers.The entity management of medical records can not effectively control and manage the formation process of medical records,which leads to the fact that the quality of medical records is not high or there are some defects when they are filed.After the reform and opening up.China's medical and health undertakings have been developed strongly,the growth of medical services has been accelerated,the number of medical records has increased rapidly,and the quality requirements of using medical records have been constantly improved.In 1982,the Ministry of Health promulgated the Regulations on the Work of National Hospitals and the Basic Requirements for the Management of Medical Records in General Hospitals of Provinces,Prefectures and Municipalities,which respectively put forward requirements for the management of medical records from two aspects of hospital management and medical records management.Especially the Basic Requirements of Medical Record Management in National Provincial,Prefectural and Municipal General Hospitals applies the concept of whole-process management to the management of medical records.This requires the medical record management department to go out of the medical record room to communicate with the clinical business department,plan,guide,supervise and assist the medical staff to write the medical record on the basis of the entity management of the original medical record.The medical record room moves the management function forward to the operation stage of medical records such as diagnosis and treatment,inspection and nursing service.The scope of work of the medical record room is no longer confined to the office of the department.The work flow needs to be advanced to the clinical business stage on the basis of the original collection,collation,identification,storage and supply.Medical record room achieves the goal of writing medical record files by planning,guiding,supervising and assisting medical staff.Writing a good medical record file into the category of medical record file management marks that the medical record file management has formally entered the stage of the whole process management pattern.Planning,guidance,supervision and assistance have become an indispensable part of the medical record file management.Under the management pattern of medical record files,the use scope of medical record files is also expanding,and the use outside the hospital is beginning to show an upward trend.In 2002,the National Conference on Health Informationization adopted the Outline of National Health Informationization Development Plan 2003-2010.In the same year,the Ministry of Health issued the Basic Functional Norms of Hospital Information System,and the management of medical records entered the era of information management.With the help of electronic medical record system,medical record information management has become an inevitable requirement of medical record file management.With the continuous development of China's medical and health undertakings,not only the number of medical records has increased rapidly,but also the utilization of medical records has put forward higher requirements for medical records information management.The whole-process management pattern of medical record files pays attention to the content of medical record files,but only pays attention to the whole-process management of medical record files can not meet the needs of rapid and timely response to the information of medical record files in the new stage.In addition,due to the lack of systematic planning,the medical record files previously built between the medical record files and the hospital information system,and the medical record files.The information can not be shared in real time,forming an isolated island of medical record information.Medical records management dilemma,the objective needs of medical records management departments seek to improve the phenomenon of information island new records management and information technology.Building medical records through electronic medical record system becomes a new task of medical records management.Medical records management needs to seek new solutions based on the original model.The use of electronic medical record system to build medical records can provide medical records information service for clinical medical services,hospital management and all sectors of society in a fast and timely manner.At the same time,with the help of electronic medical record system,collecting,organizing,storing,transferring and utilizing the information of medical record archives,realizing the information management pattern of medical record archives,can improve the connotation quality of operating medical records and improve the management efficiency of archiving medical record archives,which can not only meet the requirement of entity management of medical record archives,but also be realistic.Requirements for the whole process management of current medical records.With the convening of the National Health and Health Conference in 2016 and the promulgation of the Outline of the "Healthy China 2030" Program,how to "make good use of the medical records" has become a new problem that the medical records management departments need to answer.Health management requires medical records to be shared across medical institutions to serve residents'life cycle health management.The main body of using medical records will no longer be confined to a medical institution or a patient,but need to incorporate the information of medical records into the population health information platform,build and share medical records with public health institutions,and the resulting medical records information service will be used in the life cycle health management of residents.Continuous expansion,from text to graphics,images,audio,video,multimedia,sensing signals,from single system data to large data conversion.The scope of medical record files is extended from one medical institution to many medical institutions,and coordinated transformation from medical institutions to medical institutions and public health institutions.The data of medical record files provide information services for the integrated health management of prevention,treatment,rehabilitation and self-regulated health management throughout the life cycle.Through the production and mining of medical records data,it can serve residents'life cycle health management,and bring new contents to medical records management.The data of medical records are constantly enriched,and the management of medical records is fine to the data level.The results of medical records data management will continuously enhance the knowledge value of medical records.On the one hand,the management of medical records data will transfer the management object to the data that compose the information of medical records;on the other hand,it will enhance the value of the results of medical records management,and fully tap the value of medical records through the production of medical records knowledge.The author systematically combs the history of medical records management in the past hundred years.The author points out that the stages of medical records management can be divided according to typical events,and each stage corresponds to different management patterns of medical records;each stage of development of medical records management has clear management content.Based on the duality of medical records management and the main line of development,the author further points out that the space scope of medical records management is gradually expanding,its role is becoming more and more important,its process is more complex,and its evolution and development from entity management to information management is constantly changing.The internal driving force of the evolution and development of the medical record management pattern is to continuously meet the needs of medical record information.The results of the author's research on the evolution and development of medical record archives management have guiding significance for medical and health administrative departments,hospital managers,medical staff and medical record archivists to master the law of the development of medical record archives.