摘要
目的对医院病案信息管理中存在的问题及应对策略进行相关的探讨。方法随机抽取2019年1~12月我院接收的患者作为对照组,另外抽取2020年1~12月我院接收的患者作为观察组,每组230例,对照组患者采取常规病案管理方式,观察组患者在对照组患者的基础上采取优化增强病案信息管理,对比两组患者病案信息管理过程中的问题发生率,同时分析两组患者病案信息内容中的问题发生率,最后分析两组患者对医疗以及护理的满意度差异。结果观察组病案信息管理中问题发生率为6.96%,对照组病案信息管理中问题发生率为31.74%,组间数据差异较大,存在统计学意义(P<0.05);观察组病案信息内容问题发生率为13.91%,对照组病案信息内容问题发生率为37.83%,组间数据差异较大,存在统计学意义(P<0.05);观察组患者的满意度为95.22%,对照组患者的满意度为79.57%,组间数据差异较大,存在统计学意义(P<0.05)。结论现如今医院病案信息管理当中仍然存在各方面的问题,只有找出在工作当中出现的问题,并且总结出相应的策略,然后将优化增强过的病案信息管理运用到实际的工作当中,取得了理想的效果,值得推广应用。
Objective To explore the problems and countermeasures in the management of medical record information.Methods Two hundred and thirty patients from January to December 2019 were randomly selected as the control group,and 230 patients from January to December 2020 as the observation group.The patients in the control group were given routine medical record management,on the basis of the control group,the patients in the observation group took measures to optimize and strengthen the management of medical records information,compared the incidence of problems in the process of medical records information management in the two groups,and analyzed the incidence of problems in the content of medical records information in the two groups,finally,the difference of the two groups of patients’satisfaction with medical treatment and nursing care was analyzed.Results The incidence of problems in the medical record information management of the observation group was 6.96%,and that of the control group was 31.74%,with significant difference between the two groups (P<0.05).The incidence of problems in the medical record information content of the observation group was 13.91%,and that of the control group was 37.83%,with significant difference between the two groups (P<0.05).The satisfaction of patients in the observation group was 95.22%,and that of patients in the control group was 79.57%.The difference between the two groups was statistically significant (P<0.05).Conclusion There are still many problems in the management of medical record information in hospitals.Only find out the problems in the work,and sum up the corresponding strategies,then the optimized and enhanced medical record information management is applied to the actual work,which has achieved the ideal effect and is worth popularizing and applying.
作者
吴昊
WU Hao(Medical Records Room,Jining First People’s Hospital,Jining,Shandong 272100)
出处
《智慧健康》
2021年第14期28-30,共3页
Smart Healthcare
关键词
医院病案信息管理
问题
应对策略
Hospital medical record information management
Problems
Coping strategies
