頁籤選單縮合
題名 | 日本診療資訊管理業務的變遷=Transformation of Medical Record Management Professionals in Japan |
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作者 | 岡林良樹; 瀨戶山元一; 蔡恒惠; Okabayash, Yoshiki; Setoyama, Motoichi; |
期刊 | 病歷管理期刊 |
出版日期 | 20071000 |
卷期 | 7:1 2007.10[民96.10] |
頁次 | 頁20-25 |
分類號 | 419.26 |
語文 | chi |
關鍵詞 | 病歷管理; 健康資訊管理; 電子病歷系統; 診療資訊管理士; 高知醫療中心; Medical record management; Health information management; Electronic health record system; Health information manager; HIM; Kochi health sciences center; |
中文摘要 | 日本於公元2000年實施「診療紀錄管理體制加給制度」,即醫院的病歷管理若能做到下列9個規定,就能獲得保險的特別加點:1.所有診療錄必須被妥善保管及管理;2.必須設置「中央病歷管理室」;3.必須設置「診療紀錄管理部門或診療紀錄管理委員會」;4.「診療紀錄的保管與管理規程必須明文化」;5.必須配置「一名以上的專任診療紀錄管理者」;6.「保管與管理的診療紀錄必須可以依疾病別做檢索或抽出」;7.對於住院患者的疾病統計必須使用ICD作疾病分類;8.「所有的診療科必須對所有的出院患者製作注意事項」;9.「能提供患者診療資訊」,基於上述規定使日本醫院更重視診療資訊的管理。 日本的診療資訊管理業務是始於診療紀錄的中央管理與醫事業務,經由醫事申報系統的導入,進展到醫令系統的使用,接下來則藉由電子病歷系統做資訊的分析,醫療資訊管理業務便從診療支援型轉變成醫院營運型,將來更期待能進一步的轉移為醫院戰略型的資訊管理業務。 |
英文摘要 | In 2000, Japan implemented a new medical records administration incentive program to improve upon the current system of hospital medical record management. If hospitals are able to meet the following nine conditions, they qualify for a specific medicare reimbursements from the Government: 1. all medical records must be properly maintained and managed; 2. a centralized medical record management center must be established; 3. a medical records administration department or a medical records administration committee must be established; 4. the procedures for the medical record's storage and management must be fully documented; 5. a full-time health information manager must be appointed to the above mentioned department; 6. medical records must be stored and managed, so that they can be easily retrieved; 7. all assessment of patients' diseases must use the International Classification of Diseases to perform the nosology; 8. all medical departments must document any ongoing treatment for all patients that are released; 9. the hospital must be are able to supply all of their patients' medical information on the basis of the above regulations. These regulations are designed to encourage Japanese hospitals to pay more attention to the management of their medical records. Japan's medical information management begins with the central medical record management system and the medical practitioner. Policies are established for the medical report system, and medical instructions are made based on this system, and finally information can be analyzed according to the Electronic Health Record System. Medical practitioners can use the record system to assist with diagnosis, and because they can directly access the system the quality of service of the hospital is improved. It is anticipated that in the future the centralized record system will further enhance the hospital's entire strategy for information management. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。