摘要
目的了解内蒙古地区某医联体三级医院病案管理现状,进一步规范病案管理工作,提高病案管理人员的专业水平。方法 2017年12月采用发放调查问卷的方式,调查内容包括医院基本情况、病案科室基本情况、病案管理情况、病案质控、病案借阅等。调查表回收后,统一录入Epidata3.1,数据导出后由Excel 2010进行数据分析。结果平均编制床位与病案管理人员的配备比例为78.5:1;病案科属于独立科室的7所,占30.43%,隶属于医务处(科)的16所,占69.57%;病案收集、复印、整理等工作开展比例较高,病案质控、疾病及手术(ICD)编码、医院统计等工作开展比例较低,分别占78.26%、69.57%、56.52%;各医院都开展了终末病案质控,部分医院开展了运行病历质控、病案管理质控、疾病分类质控,分别占47.83%、69.57%、39.13%;病案质控采取计算机程序控制与手写纸质表格相结合的方式进行;各医院主要对终末病案进行质控,对门诊病案开展质控的医院较少。结论内蒙古地区三级医院病案管理工作日趋完善,但仍存在领导不重视、人员配备不足、管理项目开展少等问题,各医院应提高对病案管理工作的重视程度,提升病案管理质量水平。
Objective To understand the status of medical records management in the three level hospital of Medical Union in Inner Mongolia, further standardize the management of medical records, and improve the professional level of the medical records management staff. Methods In December 2017, a questionnaire survey was conducted in the survey hospitals, including the basic situation of the hospital, the basic situation of the medical record department, the management of medical records, the quality control of medical records, and the lending of medical records. After the questionnaire is recovered, the Epidata3.1 is entered, and the data is analyzed by Excel 2010 after the data is exported. Results A total of 23 questionnaires were issued and 23 were recovered, all of them were qualified. The average authorized beds and medical record management personnel with a ratio of 78.5：1; the department of medical records was an independent department in 7, accounting for 30.43%; belonging to the medical department（Department） 16, accounting for 69.57%; the medical record collection, record copy, record finishing work, the higher proportion of medical record quality control disease and surgery（ICD） catalog hospital statistics, to carry out the work of a lower proportion, accounted for 78.26%, 69.57%, 56.52%; all the hospitals have carried out the final part of the hospital medical record quality control, to carry out the operation of the quality control of the medical record and medical record management control, classification of disease control, accounted for 47.83%, 69.57%, 39.13%; take control of medical record quality control computer program combined with handwriting the paper form; the main hospital quality control of terminal medical records, to carry out the quality control of hospital outpatient medical records for less. Conclusions The management of medical records in Inner Mongolia three level hospitals was improving day by day, but there were still problems such as lack of leadership,inadequate staffing and less management projects. Hospitals should improve the importance of medical record management and improve the quality of medical record management.
作者
陆俪平
咸本松
闫志刚
王智慧
李耀亭
张超
云志中
Lu Liping,Xian Bensong,Yan Zhigang,Wang Zhihui,Li Yaoting,Zhang Chao,Yun Zhizhong(Medical Couplet Office, The Inner Mongolia Autonomous Region people＇s Hospital, Hohhot 010017, The Inner Mongolia Autonomous Region, Chin)
出处
《中国病案》
2018年第5期3-5,32,共4页
Chinese Medical Record
基金
内蒙古自然科学基金项目[2017MS(LH)0705]
内蒙古自治区人民医院院内基金项目(2016104)
关键词
病案管理
病案质控
病案室
Medical record management
Medical record quality control
Medical record room
