Medical Record Department of Peking University Third Hospital is an indispensable and important department for hospital management. As one of the technical departments of the hospital, it is mainly responsible for the collection, sorting, classification, coding, registration, filing, storage, supply, statistics and information services of the hospital's medical records, assisting the relevant management departments of the hospital to do a good job in the quality control of medical records, providing clinical treatment, teaching, scientific research, preventive health care and hospital management services, and providing necessary information services for medical insurance, work injury appraisal, public prosecution, prosecution, law, etc.

Since its establishment in 1958, the department has shifted from manual management to information-based electronic medical record management. Divided into five working groups: organizing group, cataloging group, copying group, statistical group, and follow-up group. In 1985, microfilm technology began to prevent the loss of medical records and save the storage space of medical records; In 1994, the computer management of the home page information management system of the medical case was used, and the case management gradually embarked on the road of computerization; In 2005, the case information system was comprehensively updated, and some inpatient cases were scanned, so that the case information from a single machine to a network management; In 2016, a unique homepage management and quality control system was developed, which greatly improved the speed and data quality of disease coding; Establish a reporting mechanism for adverse events in 2018; In 2019, the trusted archiving system was launched, achieving another breakthrough in paperless projects; Establish a statistical platform in 2020 to meet the analysis of various statistical monitoring and evaluation systems; In the same year, in order to ensure the safety of epidemic prevention and control, the APP of the Third Hospital of Beijing Medical University was launched to copy the mini program; Since 2021, we have carried out data analysis and report interpretation of DRG-related indicators for clinical departments.

The Medical Records Department has built a good personnel echelon during its development and cultivated a group of leading talents in the professional field. Currently, there are 57 employees, including 7 postgraduate students and 12 undergraduate students. Associate senior title 1 people, intermediate title 17 people. Director Chen Jianming has participated in the compilation of books on disease diagnosis, CN-DRG grouping scheme and common clinical medical terms. In the past five years, many people in the department have undertaken academic positions related to coding and statistics, and published several papers in core journals. Deputy Director Li Yang presides over hospital-level seed fund projects and participates in clinical key projects and national science and technology Ministry projects.

In the development of the  medical record department, the party building and business are deeply integrated, forming a good situation of mutual improvement. Won the 2020 Advanced Party Branch; In 2022, under the supervision of the branch secretary, the department conscientiously implemented the "triple one" system, and in the year-end assessment of the hospital discipline commission, the department won the first place in clinical medical technology (1/53); Won the 2021 National Health Commission Hospital Management Institute Medical Quality Continuous Improvement Typical Case Award and Beijing Medical Quality Management Award; In 2023, he participated in the "unplanned reoperation" medical management project of the Health Commission and won the Outstanding Case Award.

Medical Record Department of Peking University Third Hospital has made great progress in key areas such as international disease classification, statistical analysis of case data, and electronic filing of medical cases in combination with hospital construction and professional characteristics, and is in a leading position in China. In the opportunity of high-quality development of the hospital, we will uphold the fine tradition of seeking truth and pragmatism for patients, carry forward the spirit of "unity, dedication, truth-seeking and innovation", and strive for the high-quality development of the hospital!