摘要
病案归档的及时性是病案室工作的重点和难点。长期以来,由于病案延期归档的现象普遍存在,严重影响了病案信息的及时统计与有效利用,也给医院及病案管理人员带来了不必要的被动甚至纠纷。本文通过对本院2010年-2011年出院病案归档情况的观察,和对2011年中,某两个典型科室的病案归档率的统计分析,总结出了延期归档的原因:从管理人员方面来说,存在缺乏管理力度的问题;在临床科室方面,存在诸如临床工作的客观因素、医师对病案工作的重视不足、复杂病历无法按期完成,以及病案书写不规范、不完整等问题,导致病案延期归档。医院应重视和加强病案归档工作,建立有效的病案归档流程和奖惩制度,使病案信息资源被有效的利用。
Medical records filing is a key and difficult point in medical records work.For a long time,delayed filing of medical records generally exists that seriously affect timely statistic and effective application of medical records information,bring unnecessary passive even medical tangle for hospital and medical records staffs.Through observation of medical records filing situation from 2010 to 2011 in our hospital and statistical analysis of medical records filing rate of two typical departments,this article summarizes the reasons of delayed filing.From the aspect of medical records staffs,it is lack of management force;from the aspect of clinical department,it exists problems such as objective factors of clinical work,being lack of value on medical records of doctors;delayed accomplishment of complex medical records;non-standard and incomplete writing of medical records,which leads to delayed filing.Hospital should pay attention to and strengthen medical records filing and establish effective filing process and punishment and reward system that makes medical records information resource are effectively applied.Finally,this paper puts forward a series of solution countermeasures.Through operation practice,it gets better achievement,effectively decreasing delayed filing rate of medical records and increasing filing efficiency.
出处
《中国病案》
2012年第5期6-8,共3页
Chinese Medical Record
关键词
病案
延期归档
原因
对策
Medical records
Delayed filing
Reason
Countermeasure
