Vizintin Karolina
Acta Med Croatica. 2014 Mar;68(1):61-4.
To ensure and improve the quality of health care, healthcare institutions have to establish a board to create the rules on the management of medical records. The main role of the board is to design a hospital general internal document entitled Rules for the Management of Medical Records at the Hospital Information System (HIS). This document regulates the management of medical records in HIS and defines the level of access for medical staff, as well as the responsibility for entering and updating medical records in HIS.
为确保和提高医疗保健质量，医疗机构必须设立一个委员会来制定病历管理规则。该委员会的主要职责是设计一份医院通用内部文件，名为《医院信息系统（HIS）病历管理规则》。此文件规范了医院信息系统中病历的管理，并确定了医务人员的访问级别，以及在医院信息系统中录入和更新病历的责任。
