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The Prevention and Control of Occupational Diseases Law revised in 2017 abolished the qualification test and approval for occupational health examination institutions, and replaced it with record management. The record does not belong to any type of administrative permit and does not require the premise of “general prohibition”. Its core idea is that “the public law actively acts as an obligation”, which does not prohibit administrative counterpart from carrying out specific tasks, mainly information collection, supervision and management of follow-ups, and emphasizes on simplifying procedures, improving working efficiency and stimulating market vitality. It is a strategic measure of the government's reform on “release, control and service”. It has the functional significance of alleviating information asymmetry, cultivating market credit mechanism and reflecting the government's flexible supervision and management mechanisms. However, China has not yet unified legislation on record management, and individuals on the theoretical and practical circles have different understandings on the concept, operation principle, and management effectiveness of the record management. There are practical dilemmas in the record management of occupational health examination institutions, such as alienation of record management into licensing, insufficient regulation of record management procedures, and weak in-process and post-process supervision and management capabilities. It is suggested to clarify the legal nature of record management, unify and improve the record management procedures, and improve in-process and post-process supervision and management capabilities. By building a legal, scientific and systematic regulation for the record management of occupational health examination institutions, adhering to the unity of “discharge” and “control”, it could effectively safeguard the legitimate rights and interests of occupational health examination institutions, workers and employers.
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As medical record management is key to hospital management, a hospital introduced paperless practice of automatic archiving in the following practices. Clarification and identification of the scope of business system transformation, establishment of an architecture integrating various business systems, integration platform, hospital data center, archiving system and certification authority, creation of three automatic archiving processes: initial archiving, late return archiving and modification archiving, for refined management of the review and tracking of archived medical records. Thanks to this paperless management, the automatic archiving rate was as high as 95.95%for medical records, 96.47%for laboratory reports and 99.58%for medical orders respectively. A full-process and whole-cycle informationized closed loop management was achieved for the collection, archiving, review and utilization of medical records, substantially upgrading hospital informationization and medical record management.
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OBJECTIVE： To establish the management system for off-label drug use in a medical institutions， and to standardize the behaviors of off-label drug use and improve the rational drug use. METHODS： Based on evidence-based researches for off-label drug use， management system of off-label drug use was established in our hospital， and off-label drug use management was carried out. The effects of management system were evaluated with the number of records for off-label drug use and pass rate of approval as indexes. RESULTS： Since the year of 2011， the management system for off-label drug use had gradually established and improved in our hospital； the mode of registration and approval for off-label drug use was established by based on a multi-disciplinary team management and quality classification for clinical evidence. Up to 2016， a total of 252 records for off-label use were submitted， among which 159 （accounting for 59.77％） were for pediatrics and 93 （accounting for 34.96％） were for gynecology and obstetrics. Among the submitted records， 181 had passed the examination and approval， and the pass rate was 64.29％. Special prescription comments indicated that the numbers of off-label use medical orders in inpatient medical orders showed a downward trend， and the proportion of recorded medical orders of off-label use had increased from 17.33％ in 2013 to 84.00％ in 2016. CONCLUSIONS： The management system for off-label drug use in medical institutions can effectively improve the clinical understanding of off-label drug use， standardize the behavior of off-label drug use.
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Objective To identify the problems of medical record management standardization in clinical case management for the study of medical record quality and give some corresponding measures.Methods 3,000 medical records of patients in our hospital from January 2015 to December 2016 were collected and divided into control group (with 1,500 records from January 2015 to December 2015) and observation group (with 1,500 clinical medical records from January 2016 to December 2016).The control group adopted regular data management while the observation group employed standardized lean management.Medical record defects, rectification rate and the average scores of inpatient medical records between the two groups were compared and analyzed.Results The average score of inpatient medical records in observation group was significantly higher than that of the control group (t=13.672, P<0.05), while the defect degree and the modification rate of the medical records were significantly lower than those of the control group (P<0.05).Conclusion Standardized medical record management contributes to the improvement of the quality of medical records.
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El objetivo de este trabajo es identificar los elementos, procesos y sistemas de información relacionados con la gestión documental, la gestión de información, la inteligencia organizacional y la gestión del conocimiento que inciden en la toma de decisiones estratégicas de instituciones de información. Se utilizó el análisis documental para examinar los componentes y características particulares de cada uno de estos procesos gerenciales y el modo en que inciden en los máximos niveles de decisión organizacional de las instituciones de información. Se realizó un análisis descriptivo para esclarecer y precisar los recursos, los procesos y los sistemas informacionales que intervienen en la toma de decisiones estratégicas de bibliotecas, archivos y centros de información de amplio reconocimiento para el sector de las Ciencias de la Información en Cuba. Los documentos archivísticos, la información organizacional interna y externa y el conocimiento constituyen recursos clave para la toma de decisiones estratégicas. Entre los componentes asociados a estos procesos gerenciales se destacan los sistemas de gestión documental y los sistemas de información organizacional. Los procesos informacionales y cognitivos que inciden en la toma de decisiones son la identificación de necesidades de información y los flujos informativos, la búsqueda y selección de información, al análisis, así como la creación y uso de conocimiento organizacional. La toma de decisiones ha adquirido una marcada dependencia hacia los procesos gerenciales relacionados con la información y el conocimiento; de ahí su carácter informacional, por lo que se requiere una adecuada proyección e interrelación de estos para garantizar decisiones efectivas sobre la base de un buen uso de estos recursos estratégicos.
The study is aimed at identifying the information systems, elements and processes related to record, information and knowledge management and organizational intelligence which influence strategic decision making at information institutions. Document analysis was used to examine the particular characteristics and components of each of these management processes, as well as their influence on the top levels of organizational decision making at information institutions. A descriptive analysis was performed to clarify and accurately determine the information systems, resources and processes involved in strategic decision making at libraries, archives and information centers of broad recognition in the sector of information sciences in Cuba. Archival documents, internal and external organizational information, and knowledge are key resources in strategic decision making. Document management and organizational information systems stand out among the components associated to these management processes. The information and cognitive processes influencing decision making are the identification of information needs and information flows, the search for and selection of information, and the creation, analysis and use of organizational knowledge. Decision making has become heavily dependent on management processes related to information and knowledge, hence its informational nature. Therefore, these strategic resources should be appropriately projected and interrelated to ensure the effectiveness of decisions.
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Se aborda la gestión documental en el contexto organizacional actual. Se examina el concepto de documento de archivo y las complejidades de su manejo en el ambiente digital que afectan su capacidad de constituir evidencia veraz de los procesos de negocios organizacionales. Finalmente se presenta la Norma ISO 15489 Información y documentación Gestión de Documentos como una metodología útil para la adecuada gestión de documentación archivística, independientemente de su soporte, en el contexto organizacional. Se ofrecen consideraciones finales y recomendaciones
The documentary management in the current organizational context is approached. The concept of archive document and the complexity of its management in the digital environment affecting its ability to create a truthful evidence of processes of organizational business are examined. Finally, the ISO 15489 Standard is presented: Information and documentation document management as a useful methodology for a appropriate management of archives documents, independently of its support in the organizational context. Final considerations and recommendations are offered
Sujets)
Archives , Documents , Gestion de l'informationRésumé
Modern medical record management is becoming more and more integrated with medical information management and computerization.With the changes in the content and mode of medical record management,the modernization of its means and the extension of its services,the managerial personnel must have such qualities as active service idea,multiple knowledge,a high sense of information,strengthened awareness of law,and abilities of communication and coordination,so as to meet the requirement of modern medical record management.
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Objective To find out about the current situation of the development of medical record management in Jiangxi Province. Methods Questionnaires were distributed to 182 medical record management workers in 98 hospitals of Jiangxi Province. Results Medical record management has witnessed slow development and the management contingent is characterized by low educational level, low professional titles, a rather limited number of years of work experience and numerical dominance of women. Conclusion That leaders in some hospitals fail to pay enough attention to medical record management and medical record management organizations have not been properly set up constitutes the chief cause of the slow development of the medical record management specialty in Jiangxi Province.
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To change the old stereotype of using literal and data information for storage and ex- change in medico—scientific records and provide a new record version rich in word and picture,a gener- al model of multi—media control system of medical records and an information storage pattern have been developed and the feasibility of development methods explored.