摘要
目的探讨医院评审对医院病案管理的影响效果。方法回顾性分析2010年1月-2013年12月某院6521例就诊患者病案资料保存情况(对照组),2014年1月-2017年8月严格按照本市相关部门制定的医院评审标准进行病案资料的管理,统计病例7169例(观察组)。观察两组病案管理不良情况、资料录入及检索时间、管理人员绩效考核评分、医务人员满意度。结果观察组和对照组病案管理不良情况发生率分别为0.42%、1.29%,组间统计差异显著(P<0.01)。观察组病例资料录入时间及病例检索时间均明显低于对照组,组间统计差异显著(P均<0.05)。病案管理科人员绩效考核指标观察组职业素养、科研教学、工作质量和科室管理评分均较对照组高,组间差异显著(P均<0.05)。观察组中医务人员对病案管理工作满意度高达99.15%,明显高于对照组的93.98%,组间统计差异(P<0.05)。结论通过按照医院评审的标准严格科室管理,可以缩短病案录入、检索时间,提高管理人员工作质量,并降低不良情况风险,同时还能提高医务工作者满意度,促进病案室和各科室医护人员关系和谐。
Objective To explore the effect of hospital review on hospital medical record management. Methods To retrospectively analyze the storage status of 6521 patients＇ medical records from January 2010 to December 2013 （control group）. One hospital had strictly conducted the management of medical records in accordance with the standard of hospital review established by relevant departments in this municipality since January 2014 until August 2017, and had totally recorded 7169 cases （observation group）. Observed the adverse situation of medical records management, data entry and retrieval time, management performance evaluation score and medical staff satisfaction in the two groups. Results The incidence of adverse medical record management in the observation group was significantly lower than that in the control group （0.42% vsl. 29%）, and the difference between the two groups was statistically significant （P〈0.01）. The data entry time, the retrieval time of the observation group were significantly lower than those of the control group, the difference between the two groups was statistically significant （P〈0. 05）. The comparison of performance evaluation indexes of medical record management department. The scores of professional quality, scientific research＇, teaching, quality of work and management of the observation group were higher than those of the control group, and the difference between the two groups was significant （P〈 0.05）. The satisfaction rate of medical staff in the observation group was as high as 99.15%, significantly higher than that in the control group （93.98%）, and the difference between the groups was significant（P〈0. 05）. Conclusions Hospital accreditation Could shorten the medical record entry, search time, improve the quality of management work, and reduce the risk of adverse conditions. It could also improve the satisfaction of medical workers, and promote the harmonious development of medical record room and medical staff in different departments.
出处
《中国病案》
2018年第1期9-12,共4页
Chinese Medical Record
基金
华中科技大学同济医学院附属武汉中心医院院内课题(YH19803)
关键词
医院评审
病案管理
影响效果
Hospital review
Hospital medical record management
Impact effect
