摘要
目的通过对某院病案复印情况的分析,为改善病案管理工作、提高质量管理水平提供有效依据。方法以某院2019年12月1日-2020年11月30日病案复印系统统计报表中18411人次病案复印信息作为研究对象,采用Excel表格统计分析病案复印用途、复印内容以及科室分布情况。结果某院出院患者总计38578人次,其中病案复印18441人次,复印人次占总出院人次47.8%。复印用途以医保报销和商业保险报销为主,两者共占比85.48%,其余依次是复查会诊、司法等;复印内容以出院记录最多,占比17.75%,其次是住院病案首页和入院记录等;复印科室以骨科复印率最高,骨创伤科和骨病科共占比22.27%,其次是甲状腺乳腺外科、神经内科和消化科等。结论某院病案室病案的利用主要以保险报销为主。为促进病案质量管理,提高病案复印效率,工作人员须遵守病案管理规定,加强病案归档管理,优化病案复印流程等措施。
Objective Through the analysis of the copying of medical records in a hospital,to provide an effective basis for improving medical record management and improving the level of quality management.Methods Taking the information of 18,411 copies of medical records in the statistical report of the medical record copying system of a hospital from December 1,2019 to November 30,2020 as the research object,the Excel form was used to analyze the use of medical record copying,the contents of copying and the distribution of departments.Results A total of 38578 patients were discharged,including 18,441 copies of medical records,accounting for 47.8% of the total.The main uses of photocopying are medical insurance reimbursement and commercial insurance reimbursement,accounting for 85.48%,followed by review,consultation,judicature and so on.Most of the photocopies were made by discharge records,accounting for 17.75%,followed by the home page of hospitalization records and admission records.Orthopedic department has the highest copy rate,orthopedic trauma department and orthopaedic department account for 22.27%,followed by thyroid and breast surgery,neurology and gastroenterology.Conclusion The utilization rate of medical records in hospital medical records room is high.In order to promote the quality management of medical records and improve the copying efficiency of medical records,the staff should abide by the regulations of medical record management,strengthen the management of medical record filing and optimize the process of medical record copying.
作者
沈莹莹
侯兆红
Shen Yingying;Hou Zhaohong(The 960 Hospital of the people's Liberation Army,Ji'nan 250000,Shandong Province,China;不详)
出处
《中国病案》
2021年第12期4-6,共3页
Chinese Medical Record
关键词
病案
复印
改进措施
Medical record
Copying
Improvement measures
